text:
Explaining Adherence Success in Sub-Saharan Africa: An Ethnographic Study

  • Norma C Ware ,

    To whom correspondence should be addressed. E-mail:

    Affiliation: Harvard Medical School, Boston, Massachusetts, United States of America

  • John Idoko,

    Affiliation: Jos University, Jos, Nigeria

  • Sylvia Kaaya,

    Affiliation: Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

  • Irene Andia Biraro,

    Affiliation: Mbarara University of Science and Technology, Mbarara, Uganda

  • Monique A Wyatt,

    Affiliation: Harvard Medical School, Boston, Massachusetts, United States of America

  • Oche Agbaji,

    Affiliation: Jos University, Jos, Nigeria

  • Guerino Chalamilla,

    Affiliations: Muhimbili University/Dar es Salaam City Council/Harvard School of Public Health HIV/AIDS Care and Treatment Program, Dar es Salaam, Tanzania , Harvard School of Public Health, Boston, Massachusetts, United States of America

  • David R Bangsberg

    Affiliations: Harvard Medical School, Boston, Massachusetts, United States of America , Massachusetts General Hospital, Boston, Massachusetts, United States of America , Harvard Initiative for Global Health, Cambridge, Massachusetts, United States of America

Explaining Adherence Success in Sub-Saharan Africa: An Ethnographic Study

  • Norma C Ware,
  • John Idoko,
  • Sylvia Kaaya,
  • Irene Andia Biraro,
  • Monique A Wyatt,
  • Oche Agbaji,
  • Guerino Chalamilla,
  • David R Bangsberg
  • Published: January 27, 2009
  • DOI: 10.1371/journal.pmed.1000011

Individuals living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of prescribed doses of antiretroviral therapy (ART). This number exceeds the levels of adherence observed in North America and dispels early scale-up concerns that adherence would be inadequate in settings of extreme poverty. This paper offers an explanation and theoretical model of ART adherence success based on the results of an ethnographic study in three sub-Saharan African countries.

Methods and Findings

Determinants of ART adherence for HIV-infected persons in sub-Saharan Africa were examined with ethnographic research methods. 414 in-person interviews were carried out with 252 persons taking ART, their treatment partners, and health care professionals at HIV treatment sites in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda. 136 field observations of clinic activities were also conducted. Data were examined using category construction and interpretive approaches to analysis. Findings indicate that individuals taking ART routinely overcome economic obstacles to ART adherence through a number of deliberate strategies aimed at prioritizing adherence: borrowing and “begging” transport funds, making “impossible choices” to allocate resources in favor of treatment, and “doing without.” Prioritization of adherence is accomplished through resources and help made available by treatment partners, other family members and friends, and health care providers. Helpers expect adherence and make their expectations known, creating a responsibility on the part of patients to adhere. Patients adhere to promote good will on the part of helpers, thereby ensuring help will be available when future needs arise.

Adherence success in sub-Saharan Africa can be explained as a means of fulfilling social responsibilities and thus preserving social capital in essential relationships.

Editors' Summary

The acquired immunodeficiency syndrome (AIDS) epidemic has killed more than 25 million people since 1981, and about 30 million people (22 million in sub-Saharan Africa alone) are currently infected with the human immunodeficiency virus (HIV), which causes AIDS. HIV destroys immune system cells, leaving infected individuals susceptible to other infections. Early in the AIDS epidemic, most HIV-infected individuals died within ten years but in 1996, combination antiretroviral therapy (ART)—a mixture of powerful drugs—was developed. For HIV-infected people living in affluent, developed countries, HIV/AIDS became a chronic disease, but for the millions of infected people living in low- and middle-income countries, HIV/AIDS remained a death sentence—ART was simply too expensive. In 2003, this situation was declared a global health emergency. Today, through the concerted efforts of governments, international organizations, and funding bodies, nearly one-third of the people in developing and transitional countries who are in immediate need of life-saving ART receive free, reliable supplies of the drugs they need.

Why Was This Study Done?

For ART to work, it must be taken regularly. If drug doses are missed, the virus can rebound and resistance to ART is more likely to develop. In poor countries, even though free antiretroviral drugs are increasingly available, many obstacles to good adherence to ART remain. These include economic obstacles (for example, the cost of traveling to clinics and the loss of earning associated with clinic attendance), and social, cultural, and behavioral barriers. Some patients fear disclosure, for example. Others receive conflicting messages about the benefits of ART. However, despite worries that the scale-up of ART provision in developing countries would be dogged by inadequate adherence, people living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of their prescribed doses of ART, a better level of adherence than in North America. In this study, the researchers investigate why ART adherence is so high in sub-Saharan Africa by analyzing qualitative data from an ethnographic study done in Nigeria, Tanzania, and Uganda. Qualitative data are often used to address “how” and “why” research questions: ethnography is a comprehensive qualitative approach to describing and explaining human behavior and culture.

What Did the Researchers Do and Find?

For their study, the researchers interviewed 158 patients, 45 treatment partners (lay-people who help HIV-positive people keep to their treatment), and 49 health care workers. Patients were asked about their experiences of ART and about the help they received from their treatment partners; partners were asked about the type of help they gave and about their feelings about this help; health care workers were asked to describe a typical clinic visit and to indicate how adherence was discussed. From these interviews and observations of clinic sessions, the researchers identified several strategies used by patients and their treatment partners to overcome economic obstacles to ART adherence. These included borrowing and “begging” funds to pay for travel to clinics and making “impossible choices” to prioritize adherence, and “doing without.” The researchers' analysis also indicates that the prioritization of adherence to ART reflects the importance of relationships as a resource for managing economic hardship. So, for example, they found that treatment partners and health care workers expected patients to adhere to ART (which, by improving patients' health, improves their ability to support themselves and their families) and made their expectations known, thereby creating a responsibility among patients to adhere. Patients, in turn, adhered to their treatment to promote good will from their helpers and thus ensure their continuing help.

What Do These Findings Mean?

The findings offer a possible explanation of adherence success in sub-Saharan Africa. The high level of adherence to ART can be explained as a means of fulfilling social responsibilities. Adherence, the researchers suggest, not only improves personal health (the main driver for ART adherence in resource-rich environments) but also preserves “social capital” in essential relationships. In other words, in sub-Saharan Africa, adherence to treatment may protect the relationships that individuals living in extreme poverty rely on to help them survive.

Additional Information.

Please access these Web sites via the online version of this summary at000011.

People living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of prescribed doses of antiretroviral therapy (ART) [112]. This number exceeds the levels of adherence observed in North America [13] and dispels early scale-up concerns that adherence would be inadequate in settings of extreme poverty [1416].

These near-perfect levels of adherence are being achieved despite formidable obstacles in the poorest regions of the world. Prohibitive costs of self-pay medications and drug stock-outs create insurmountable access barriers and lead to missed doses [3,7,10,12,1720]. Expanding access to free ART and better distribution systems are addressing these obstacles. However, out-of-pocket expenses, including user fees, laboratory tests, and transportation over often long distances to and from treatment sites remain important barriers to sustained adherence and medical care [5,2124]. Time spent traveling to and attending clinical appointments places additional economic strain on patients and their families by competing with income generating activities. Failure to negotiate economic obstacles can lead to ART interruptions, viral rebound, and resistance to limited available regimens [2,25].

Social and cultural obstacles also threaten adherence success. Stigma and the fear of disclosure cause patients to skip doses if privacy is unavailable at a scheduled dosing time [5,21]. Conflicting messages from health care practitioners and religious authorities may also interfere with adherence [26,27]. Behavioral obstacles similar to those observed elsewhere, including forgetting doses, fear of side effects, traveling without medications, and stopping drugs when symptoms disappear have also been reported for sub-Saharan Africa [3,4,10,18,25,26].

Adherence facilitators in resource-scarce settings have received less attention than adherence barriers. Currently, home-based adherence “help” is emerging as an important resource to support adherence. One form of home-based help centers on community health workers. Community health workers are laypersons trained and paid through treatment programs to provide adherence support and other services at home. They deliver medications, observe dosing, refer individuals for HIV-testing, offer encouragement, provide nutritional and housing support, help with transportation, and in general represent important links between clinics and communities [22,2832].

A second form of home-based help is treatment supporters [33]. Treatment supporters (also termed treatment “partners” and treatment “assistants”) are laypersons nominated by patients to help with treatment adherence. They remind patients of dosing times, and often (though not always) witness dosing. They are not health care workers, but individuals with close personal ties to patients. As family members or friends, treatment supporters often live in the same or a nearby household. Treatment supporters are not specifically trained or paid, but nonetheless make a formal commitment to their role. Early studies suggest that both treatment support and community health worker approaches to home-based help may improve treatment outcomes [4,22,28,34].

More structured support in the form of clinic-based modified directly observed therapy (MDOT) has shown promising results in Kenya [35]. The factors accounting for the observed benefit of MDOT are currently unknown. Results of similar initiatives in the United States are more mixed [36,37].

To better understand exceptional adherence in sub-Saharan Africa, we analyzed qualitative data from an ethnographic study carried out in three countries: Nigeria, Tanzania, and Uganda.

Study Design

This patient-centered ethnographic study took place in public HIV-treatment settings in Nigeria, Tanzania, and Uganda (see Table 1). The HIV/AIDS Clinic at Jos University Teaching Hospital (JUTH) is located in a medium-sized city in Nigeria's central plateau and currently follows more than 8,400 patients prescribed ART. The ART Clinic of Amana District Hospital is located in Dar es Salaam, Tanzania, and currently follows approximately 5,300 patients on ART. The Immune Suppression Syndrome (ISS) Clinic at Mbarara University of Science and Technology is located in rural southwest Uganda and currently follows approximately 7,000 patients prescribed ART. A wide range of geographic and social variation is represented across the three sites.

Table 1.

Study Site Characteristics

We used a purposeful sampling design. The goal of purposeful sampling is to systematically represent a variety of perspectives on the topic under study [38]. Three different perspectives chosen for relevance to the topic of adherence were represented in this research: (1) patients; (2) treatment partners (termed “assistants” at the Tanzanian site); and (3) health care providers. In Nigeria and Tanzania, random samples of potential patient participants were drawn from the larger populations of adults meeting inclusion criteria. Inclusion criteria were: (1) age 18 y or older; (2) prescribed antiretroviral therapy for HIV/AIDS for no fewer than 6 and no more than 12 mo at the time of sampling; and (3) residence within 20 km of Jos University Teaching Hospital or Amana District Hospital. In Uganda, patient participants were drawn from the larger Uganda Antiretroviral Treatment Outcomes (UARTO) study, a prospective study of antiretroviral-naïve patients initiating ART led by one of the authors (DRB).

Treatment partners who participated in the study were referred by patient participants. Patients were asked to name “someone who assisted them in their efforts to take antiretroviral medications.” Health care providers who participated were volunteers who responded to a letter of invitation introducing the study.

In Nigeria and Tanzania, patient participants were recruited at the clinic during routine follow-up visits. At a free moment (e.g., while waiting to be seen or at the conclusion of the visit), staff approached eligible individuals to describe the study and extend an invitation to participate. In Uganda, permission to contact prospective patient participants for recruitment was first obtained by UARTO research staff. Once permission was obtained, a research assistant for this ethnographic study approached the participant for consent.

Treatment partners were visited or telephoned by staff after giving permission for contact. Health care providers who indicated interest in response to the letter of invitation were invited to participate.

The research was approved by the institutional review boards at Harvard Medical School (Boston, Massachusetts, United States); Jos University Teaching Hospital (Jos, Nigeria); Muhimbili University of Health and Allied Sciences (Dar es Salaam, Tanzania); Mbarara University of Science and Technology (Mbarara, Uganda); and the Uganda National Council for Science and Technology (Kampala, Uganda). Written informed consent was obtained from all participants.

Data Collection

Data were collected through in-person qualitative interviews and observations of clinic activities. Information on adherence was collected through the 3-d self-report instrument from the AIDS Clinical Trials Group edited and adapted for cultural context [39]. All data were collected by African researchers. The researchers were Nigerians, Tanzanians, and Ugandans who had been trained in ethnographic data collection techniques by two of the authors (NCW and MAW).

In-Person Interviews

Multiple interviews were conducted with patient and treatment partner participants to allow for elaboration of areas whose significance emerged as analysis proceeded. The interviews were semistructured, meaning that predesignated core topics, but not specific questions, were covered in each session. This approach ensured that specific areas were covered in each interview, but also allowed unanticipated themes to emerge. Core topics for patient interviews included: (1) specific experiences of taking ART (e.g., “stories” of the most recent dose taken, most recent dose missed); (2) clinic visits; (3) help received from treatment partners. Core topics for treatment partner interviews included: (1) types of help provided; (2) feelings about being a treatment partner; (3) perceptions of the impact of help. Core topics for health care provider interviews included: (1) description of typical clinic visit; (2) the ways adherence comes up in clinical visits; (3) perceptions of barriers to adherence for patients.

The goal of the interviews was to understand ART adherence from the interviewees' points of view. Patient participant and treatment partner interviews were conducted in homes or at other locations of the interviewee's choosing outside the clinic. Health provider interviews were conducted at the clinic. Privacy was protected by conducting the interviews in locations where the conversation could not be overheard. Interviewees had the option of conducting the interview in the local language (Hausa, Kiswhahili, Runyankore) or in English. Interviews were audio-recorded with permission and averaged about an hour in length. Patients received compensation in the form of reimbursement for transportation (where applicable) or a small stipend.

Field Observations

Observations are a hallmark of ethnographic data collection. They involve the presence of a researcher in a naturalistic setting and the witnessing of events and activities of interest to a given research inquiry [40]. Observations have the advantage of providing a direct view of phenomena under study to complement one that is mediated through verbal interview reports. The following activities were observed by research staff at each of the clinical sites: (1) routine follow-up visits of patients taking ART; (2) counseling sessions; (3) health education sessions; and (4) the dispensing of antiretroviral medications. Observation sessions lasted 30 min to 1 h.

Data Preparation

Shortly after the completion of each interview, the interviewer produced a detailed write-up in English on the interview content, using the audio-recording and notes taken during the interview to ensure accuracy and completeness. The interview write-ups took the form of “stream-lined” transcripts. A “stream-lined” transcript is produced in English (without first transcribing in the local language) and consists only of interview questions asked and their responses. This approach to data preparation has several advantages. First and foremost, it captures the desired level of detail often lost in a summary and preserves the exact words of the interviewee. It can be completed in a reasonable amount of time by the interviewer, eliminating the expense of separate transcription. Accuracy is also improved using this approach. The write-ups contain a section in which the interviewer adds relevant contextual details and impressions not captured in the transcript. Descriptions of activities observed were written up following each session as field notes.

Data Analysis

Analysis aimed at explaining adherence to ART using an inductive approach to category construction and interpretation of data [41,42]. Descriptive categories were constructed to characterize approaches to overcoming economic obstacles to care. To construct the categories, content related to patients' adherence experiences was retrieved from coded data. Relevant sections of text were identified, copied, and grouped according to the type of adherence obstacle represented. These sections of text were then reread to characterize the ways in which patients negotiated these obstacles to avoid missing doses and clinic visits. The data were re-organized in terms of these characterizations to produce an initial category “set.” Each category forming the set was named, defined, and illustrated through interview excerpts. The set was refined—revised, specified, and elaborated—through successive returns to the data in which additional sections of relevant text were extracted. Interpretive analysis used a theoretic social science construct to develop an argument based on the categories. The data suggested “social capital,” i.e., resources accruing from social networks, as the best explanatory construct to interpret adherence strategies and explain their success.

Study Participants

158 patients, 45 treatment partners, and 49 health care providers participated in this study. 414 interviews and 136 observation sessions were conducted across the three sites.

Characteristics of Study Participants

Approximately two-thirds (65%) of patients who participated in this study were women. The mean age of the patient group was 38 y. Less than half (44%) were married or living with a partner. Approximately three-quarters (71%) of the patients were Christian; the remainder were Muslim. Primary school was the highest level of education completed for slightly more than half (57%) of the patient sample. 65% of patients met criteria for Stage III or Stage IV disease according to World Health Organization (WHO) criteria at initiation of HIV care.

Treatment partners.

More than half (56%) of treatment partners were female. The mean age of the group was 39 y. Three-quarters (73%) were married or living with a partner. 60% were Christian; the remainder were Muslim. Primary school was the highest level of education completed for about a third (35%) of the group.

Health care providers.

Approximately two-thirds (64%) of health care provider participants were women, and the mean age of the group was 38 y. About a quarter (27%) of the sample were physicians; a third (35%) were nurses. Nineteen percent were counselors and 16% were pharmacists or medication dispensers. Two full-time “tracking” officers, responsible for locating patients lost to follow-up, were included in the sample (2%), as was another expert patient fulfilling an administrative function (1%).

Ethnographic Data

On the basis of category construction and interpretation of the data, we organized the findings from ethnographic data to demonstrate: (1) prioritization of adherence to overcome economic obstacles, and (2) responsibility in social relationships as an explanation of prioritization.

Prioritizing adherence to overcome economic obstacles.

Participants reported that most adherence obstacles were related to resource scarcity. Resource scarcity means that basic commodities required for daily living are not easily available. For example, obtaining money for transportation to clinic appointments (where prescriptions are refilled) is rarely a simple matter of dipping into a ready supply of cash. Concerted effort and specific strategies were required to raise needed funds to secure medications.

Patient participants spoke of raising transport funds through loans and handouts, what they termed borrowing and “begging.” Loans—from treatment partners and other family and friends—were a reliable source of cash but were expected to be repaid, often with interest. Some interviewees reported selling possessions or earning income through work to repay loans. Others borrowed repeatedly but saw no way to resolve the debts they had incurred. Chronic indebtedness was a source of considerable emotional distress for borrowers, as these interview excerpts indicate: “Most times I borrow money [to get to clinic] and worry about re-paying the debt.” (Interviewer: “How do you re-pay the debts?”) “I work and look for money digging and weeding in people's plantations.” And: “When you do not have money you think of how you will come to clinic for medicine. [Last time] I borrowed from a friend but now I have paid it back.” (Interviewer: “How did you feel about borrowing?”) “I felt raw and depressed because I got worried. Actually I lost kilograms. When I came to the clinic and got weighed I had lost 2 kgs.”

Treatment partners reported borrowing to help patients. In the following excerpt, a treatment partner describes how “having friends who have shops” provides access to credit that enables her to accommodate the food preferences of the patient she helps, who is not doing well: “The patient is seriously sick now. She is not ok. And when patients are seriously sick they lose their appetite. If you give her beans she will not eat. So we are borrowing rice from people with shops. They trust us and they lend, paying is a problem. I live with good neighbors who have shops. They help me, and at the end of the month I pay them. She likes rice very much. If you cook rice with anything, she eats.”

Requesting handouts of cash—termed “begging” by interviewees—was also reported. Handouts were not expected to be repaid. Interviewees “begged” handouts for transport funds from family, friends, and health care providers: “If I see the date [of clinic visit] is approaching, I will start begging for help. I tell people the date of my clinic is coming and that I don't have money, so they should assist me.” And: “Sometimes I beg or ask for money to attend the clinic. Sometimes I have money for going there and beg at the clinic [for money to return]. Last time my uncle gave me money to go there. To get back I had to beg for money from the doctor.”

Cash in hand, whether borrowed, “begged,” or earned, is immediately subject to competing claims. As a result, patient participants were continually confronted with “impossible choices”: HIV care or treatment for a sick child? HIV care or school fees? HIV care or food for the family? Resource scarcity sometimes required denying the needs of loved ones in order to secure money for transportation to clinic: “Seven days before going to get the medicine, I try to look around for money. If it means not eating or buying food for the children I do that, because they told us that we are not supposed to miss …”

Food, essential to survival and functional recovery while on ART, was often treated as expendable. Patient participants understood that taking medications with food and adhering to a healthy diet that includes a variety of food groups is important for their treatment and recovery on ART. Though reluctant to ignore doctors' orders, patient participants sacrificed their own need for food to meet the needs of others close to them: “If I don't have porridge [when I take the pills] I feel nauseated. [But at times it's hard to get porridge] because I buy it with money and when it's the school fee season there is no money.”

Strategies for obtaining help from others notwithstanding, there are times when patients simply “do without.” They do without food, but take their medications anyway, despite hunger-induced exacerbation of ART side effects. They do without transport, and walk to clinic, which can often take several hours: “It's hard to take meds without food. When I take meds without food I get a stomachache. But you can't miss meds because of food. I take meds with an expectation that I may get food later.” And: “[When there's no food] I just take [the drugs] on an empty stomach. And I will feel like vomiting – dizzy, weak and all. When I don't eat before taking drugs, honestly, I don't find it easy at all.” And: “Five months ago the car got spoilt and now I am walking to the clinic. At first I had money for a [motorcycle taxi] but now I do not even have that. I will continue walking whatever happens.”

Borrowing and “begging” transport funds, making impossible choices, and “doing without” are ways of overcoming the economic obstacles that continue to block access to treatment for HIV/AIDS despite the availability of free ART. These sacrifices reflect the extraordinary efforts and commitment of individuals who are assigning “first priority” to HIV care: “Taking meds is my life. I have to give meds first priority because they are helping me.”

Explaining prioritization: adherence to improve health and fulfill responsibility in social relationships.

As in resource-rich settings, the immediate reason patients assign “first priority” to adherence is to improve health. Patient participants described profound improvements after starting ART, as grave illness gave way to weight gain, renewed energy and strength, and the ability to care for themselves. With treatment, most patients returned to normal activities, including income-generation. Clinical improvement also brought renewed hope for a long life. The restoration of health and hope, together with the memory of previous suffering and the threat of jeopardizing what has been gained should adherence lapse, provide powerful motivation to take ART correctly.

However, the pursuit of health does not completely explain why patients assign first priority to adherence. For African patients, good health is important because it helps to preserve relationships with others.

The contribution of social relationships to mental and physical health is well-documented for North America [4347]. In settings of economic scarcity, relationships are not only important for health but also essential to survival. Our data suggest the prioritization of adherence reflects the importance of relationships as a resource for managing economic hardship.

Chronic illness is always hard on close relationships. But when health care is a scarce resource, illness imposes an extra burden on social intimates who must then assume responsibility for care. Care provision means investing valuable time, energy, and financial resources to promote the patient's health. The investment is justified when there is an expectation of recovery, but becomes harder to defend if it appears the illness may be terminal. When an illness is considered terminal, caregivers may look for ways of severing their connection with the patient and ending the drain on scarce resources. One interviewee explained it this way: “When I fell sick, some of the people in my family thought I was going to die soon, so they advised my brother and sister (whom I was living with) to look for transport to send me back to the village. Some people, if they see you in terminal illness, they start to value their money. They think, ‘this illness is getting worse. It'll really cost me to transport a dead body, whereas to arrange to transport a living body is different….'”

Patient participants in this study received adherence assistance from several sources. In addition to money for transport, treatment partners, other family and friends, and fellow patients provided regular reminders of dosing times. They offered encouragement by emphasizing the benefits of treatment and continually reinforcing the importance of taking medications as prescribed. Treatment supporters also worked to destigmatize HIV/AIDS. They socialized in public with infected persons; likened HIV/AIDS to common, but less stigmatized conditions (e.g., malaria); and challenged myths by deliberately sharing food and eating utensils. “…when they [a set of friends of the patient] started understanding the problem [HIV/AIDS], everybody started withdrawing from eating in the same container with him. …I saw everyone was running away from him so I called him and lied to him. I did not want to create division and break him the more. So I told him, ‘look, I met one of your doctors and she told me that you have to be very careful because of infection. You don't eat anything anybody else eats, you don't use the same cup anybody else uses, because you could get another infection and it could be even worse.' And then I ate with him, so the others would see.”

Health care providers were also important sources of help. They supported adherence through education, reinforcement, even the organization of care. At one site, providers maintained a flexible schedule to accommodate patients, even though it made their days longer. They instituted a policy of accepting “latecomers”—individuals who arrived after the deadline for being seen on a given day had passed.

Not infrequently, providers stepped outside their professional roles to make resources available to those in need. They provided money and food at their own expense, and organized larger efforts to generate support. In the following quote, a provider describes her practice of helping indigent women patients toward financial independence by securing small loans and then indicating how they might use the funds to start small businesses: “I say, ‘go around in your area, your community. Look at what people like that is not available there. Go and get some of these things and begin to sell them.' That is how I do it.”

Providers expected adherence and did not hesitate to make their expectations known. In clinic, staff communicated expectations of adherence by stating repeatedly that antiretroviral therapy must be taken as prescribed. In extreme cases, they even threatened those who repeatedly missed clinic appointments with withdrawal of access, as we see from the following report: “I told [the patient] this morning, ‘You had better decide if you are going to take these drugs. Because the way you are doing, you are creating resistance. I am giving you my last warning. If you come next time with the same story, even if you beg from heaven, we will discontinue you.' That is what I told her. (Interviewer: And would you really?) If she comes back with the same story, I am serious. We will discontinue her. We will.”

Treatment partners also expected adherence. As one person put it: “We insist she take her meds. We help her because we want her to take her meds….If you don't take your meds, you will die.”

Friends and family members taking responsibility for someone's well-being were sensitive to the fact that adherence meant “doing well,” and “doing well” made their job easier. They insisted on adherence as a gesture aimed at reducing what one treatment partner termed the “work” of care. He explained this way: “If he [patient] continues well, the work of caring for him will be over. If he continues well, I can visit him at the time I want. But if he is sick, I have to help him so he will be okay and everyone else can continue with their business. That's why I insist, ‘my relative, don't ignore what they instruct you to do. If they tell you to take [ART] in the morning and evening—do it! Don't feel it is difficult work and don't feel tired.'”

Making a similar observation, someone else said: “[Before the patient improved] it was difficult. I had to be there all the time. I kept the time for meds in my mind instead of him. I was unable to go anywhere or do anything else before he takes his meds. Now I'm free to do anything at any time without having many thoughts.”

Social expectations of adherence create obligations on the part of patients, who must meet these expectations to preserve relationships with helpers. By taking ART as prescribed and “doing well,” patients reduce the burden of help and acknowledge the work of care. This in turn fosters continued good will on the part of helpers and reinforces the likelihood that assistance will be available when future needs arise. In settings of poverty, where “community safety nets” [48] replace public entitlements as resources for weathering economic crises, the consistent good will of potential helpers is required for survival.

Our data point to economic obstacles and the strength of social relationships as principal mediators of sustained adherence in sub-Saharan Africa. These obstacles are being routinely overcome through strategies aimed at prioritizing adherence. Prioritization is accomplished with help from others. The relationships that provide this assistance are a critical resource not only for supporting adherence, but for managing economic hardship more generally. In social science, the use of relationships to obtain benefits and achieve desired ends has been termed “social capital.”

In North America, adherence to ART for HIV/AIDS has been interpreted as the product of information, motivation, and behavioral skills operating at the individual level [49]. Such an interpretation depicts the individual as the primary agent of behavior, and de-emphasizes social context.

As an analytic construct, social capital has been characterized as a property of individuals and of organizations. It has been used in the U.S. and Europe to examine the dynamics of civic engagement [50], the accomplishment of social action [51], and the production and reproduction of inequalities [52]. The ingredients of social capital (trust, cooperation, reciprocity, sociability) have been well-studied, and care has been taken to distinguish social capital from other forms of capital (e.g., economic, human, symbolic) [53]. Analysts agree on the characterization of social capital as a resource grounded in networks of social relationships. We define it as “resources accruing from a network of relationships that help individuals to solve problems and get things done.”

The concept of social capital adds considerable explanatory power to the study of HIV/AIDS in sub-Saharan Africa. It explains not only adherence success, but also the threat of stigma. Stigma is feared because it leads to social isolation, undermining relationships that are essential to survival. Avoiding HIV-related stigma can be understood as an effort to conserve social capital, a necessary resource in settings of poverty.

Relationships confer responsibility in addition to providing resources. Recipients of help must recognize what they receive and reciprocate. To ignore these responsibilities is to risk resentment on the part of helpers. Adherence allows patients to meet social responsibilities by preventing health decline and reducing the need for support. This creates a positive feedback loop in which social relationships help patients overcome economic barriers to sustained adherence. Adherence in turn fulfills responsibilities to others. Recognizing and fulfilling responsibilities to helpers through adherence strengthens social relationships and ensures more help will be available in the future.

Preservation of social capital lies at the heart of our explanation, but we recognize influences in other domains. These include: (1) social structure, e.g., patterns of inequality; (2) infrastructure, e.g. weaknesses in health systems; (3) culture, e.g., values, religious beliefs; and (4) individual experience and behavior, e.g., side effects, lack of information, psychological distress. We offer here a social relational theory to explain adherence differences between resource-rich and resource-poor settings, while acknowledging other kinds of determinants that merit further study.

Qualitative analyses contribute to quantitative research in medicine and public health by delineating useful constructs and testable hypotheses. In detailing the explanatory power of social capital, we point to its likely predictive value in examining hypotheses such as: Greater social capital will be associated with better ART access and adherence. Verification of such hypotheses will guide interventions to sustain adherence and improve treatment effectiveness.

A question that immediately arises is whether the benefits of social capital are sustainable? How long can patients realistically expect to receive resources from others who are struggling with resource scarcity themselves? Social capital, unlike many other forms of capital, increases with use [54]. However, while it may explain how economic obstacles to adherence have been overcome to date, it leaves the fundamental problem of poverty unaddressed. Caregiver efforts to compensate for the effects of poverty are not a substitute for affordable transportation, plentiful nutritious food, clean water, adequate living situations, and accessible and effective medical care. Eliminating underlying economic obstacles will reduce the strain on relationships and thus help to sustain both social capital and adherence.

We are not the first to address the social dimensions of adherence to ART in the context of international scale-up. A call for a biosocial framing laid out general principles of a socially grounded analysis and proposed relevant analytic concepts—social capital among them [55]. The importance of explaining adherence success in sub-Saharan Africa was stated specifically in a more recent account, which offered an anthropological history of treatment access and introduced “therapeutic citizenship” as an explanatory construct [56]. We propose an alternative construct emphasizing interpersonal relations, and add supporting data.

There are several limitations to our findings. First, African societies are highly heterogeneous. We collected data in urban and rural settings in East and West Africa. However, the extent to which these concepts explain adherence behavior in other African contexts will be an important area of future study. Second, we have developed a social explanation but left other domains of influence unexplored. As we develop theoretical models of adherence for resource-scarce locations, these types of influences should be more comprehensively represented. Third, while ART scale-up has been highly successful, the dynamics of adherence will likely evolve as patients confront long-term treatment. Finally, we draw upon social capital as an explanatory construct, but stop short of elaborating underlying cross-cultural differences in definitions of personhood [57].

Like persons living with HIV/AIDS all over the world, sub-Saharan Africans adhere to ART because they want to be healthy. But the desire for health alone does not adequately explain adherence success. A more complete explanation highlights the role of social capital in relationships as a resource for prioritizing adherence and overcoming economic obstacles to care. Adherence preserves social capital by protecting relationships required for survival in settings of poverty. This may be what patients are referring to when they tell us they have “no choice” but to adhere.

The contributions of the following individuals and groups to this study are gratefully acknowledged by the authors.

Data Collection: Grace Alechenu Awoleye, BSc; Nancin Dadem, MA; Nneka Emenyonu, MPH; Mary Gunde, BSc; Salmanu Inuwa; Joyce Kahembe, MA; Lillian Namukasa, BA; Angelina Mwimba, BA; Elizabeth Ndakidemi, MA; Madeleine Smith, MSW.

Facilitating the Research Process: Ayubu Kibao; Winnie Muyindike, MBChB, MMed; the staff at Jos University Teaching Hospital HIV/AIDS Clinic, Jos, Nigeria; the staff at Mbarara Regional Referral Hospital Immuno-suppression (ISS) Clinic, Mbarara, Uganda; the HIV Care and Treatment Clinic (CTC) team at Amana District Hospital, Dar es Salaam, Tanzania; the Muhimbili University of Health and Allied Sciences–Dar es Salaam City–Harvard School of Public Health (MDH) HIV/AIDS Care and Treatment Program.

Development of concepts and critical reading of the manuscript: Ben Bellows; Elvin Geng, MD; Johanna Crane, PhD; Carole Mitnick, ScD

Author Contributions

NCW, JI, SK, MAW, OA, GC, and DRB contributed substantially to the conceptualization and design of the study. MAW participated in the acquisition of data. NCW, JI, SK, and MAW contributed to data analysis and interpretation. NCW, MAW, and DRB contributed to the drafting and editing of the manuscript. NCW, JI, SK, IAB, MAW, OA, GC, and DRB approved the final version.

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Sunday, March 24, 2013

Menu Plan–March 24

Easter week is here!  I am so excited.  Sunday brings my favorite holiday and I get to host our Easter brunch after church this year.

Be sure to stop back this week as I share some Easter-specific recipes this week.  I already shared 25 Easter recipes earlier today, but get ready for some fun ones coming this week.

Before we jump into this week’s menu, I have to say we made a new casserole last week that Frog Prince and I really enjoyed.  Un-stuffed Cabbage Casserole.  If you missed it, you can get that recipe here

We also celebrated my mom’s birthday on Saturday and I brought the mixed berry no-bake cheesecake.  We can’t get enough of this dessert; its our third time making it in less than a month.

Oh, and one more yummy dinner from the archives we brought back last week - Smothered Aussie Chicken.  I forgot how good this recipe is – we had not made it in years.  That will change.

Our Easter menu, served alongside ham, looks something like this:

The rest of our week consists of:

Granola and dried fruit
Egg Salad Sandwiches {new}, steamed veggies
White Cheddar Mac and Cheese, steamed green beans

To do: Thaw spaghetti sauce, cook pasta

Granola and yogurt with berry sauce
Three Cheese Baked Ziti, steamed broccoli

To do: Make brown rice, thaw chicken, slice mushrooms

Easter Bread French Toast {new}
Chicken and Brown Rice Bake, red pepper sauté

To do: Make dessert for Bible study

Leftover French Toast, berry sauce
Bible Study: Blueberry Lemon Oat Bars

To do: Thaw Italian sausage for soup

Scramble Melt, oranges
Meatball Tortellini Soup

To do: Shred carrots for muffins and pancakes

Friday {Good Friday}
Morning Glory Muffins {new}
Veggie Pancakes {new}, steamed veggies

To do: Make pound cake, make lemon curd for dessert

Blueberry Buttermilk Waffles

To do: Shred potatoes and prepare hash brown casserole, cook ham in the crockpot, cook bacon, make citrus punch, make deviled eggs, make crescent rolls, make dessert.

Menu Plan Monday is hosted at Organizing Junkie - stop by for hundreds of menus

Find more great menus at OrgJunkie’s Menu Plan Monday!

  1. Easter is my favorite holiday, too. I'll be making ham in the crock pot for the first time, was excited to see that that's how you do it!

  2. Looks delicious! I am off this year, lol. The only thing I have to make is a bavarian jello salad. Pretty tough:)

  3. All of the food photos are making me so hungry.

Thanks for stopping by! I'd love to hear from you; especially how you're finding JOY in your kitchen.

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text:
Just kill me now, please.

1am- not feeling so good.
1:15am- hear someone puking in the bathroom. It’s Tony.
2am- have cramping, chills and naseua. “The runs” set in.
3am- Still have all of the above. (The eating disorder in me is secretely happy becasue I’ll lose weight, then the protective mother in me gets scared, wondering if food poisoning can hurt my baby, so I call Kaiser and am told to go to urgent care immediately.)
3:15am- Take a shower, get dressed to go to the hospital. Listen to Tony puke some more. Check Ethan to see if he still has a fever, give him his medicine.
3:30am- Sneeze, puke and piss myself all at the same time WHILE MY HUSBAND WIPES THE PISS FROM MY LEGS. Continue to puke for the next 20 minutes while my husband runs and pukes in the other bathroom.
4am- Convince my husband that I can drive alone to the hospital. Get there and am hooked up to a monitor.
The next 2 hours, puke, diarrhea, puke, cramp, and cry.
6am- Freak out because they tell me they are going to have to hook me up to an IV.
6:15am- Get one vein poked, prodded and poked some more with IV, cry and moan in pain, almost pass out at the site of blood because the vein collapsed. Another nurse comes in, tries again in the same area. Fails. Pokes the other arm, fails. I cry and cry and moan and beg them to let me go home. Finally, the IV is inserted.
7am- Given a shot in the hip to stop the throwing up. Cry more from the stinging pain.
8-11- Get up to go to the bathroom ever 5 minutes. Find out my husband dropped the kids off at my mom’s house, only to be sent home for puking.
12- Have blood drawn.
4pm- Given another shot for the vomiting, this time through the IV tube, SCREAM IN PAIN BECAUSE IT BURNS AND STINGS SO FUCKING BAD.
4-7pm- sleep, shit, sleep and shit again. Finally am released.
7:30pm- Go to pick up the boys at my mom’s house. Find Andrew on her bathroom floor crying that he’s going to throw up but he’s afraid he’ll choke and not be able to breathe (just like me) Ethan is burning up with fever. I have the shits again, my body aches.
Now I sit here, still feeling like shit, still having the shits, taking care of 2 sick boys, one who is terrified to throw up.
So, how the hell was YOUR DAY?

26 thoughts on “Just kill me now, please.

  1. melly

    It sounds like you all have the stomach flu that I postponed my trip over. Not that I have ever pooped in my life. Because I don’t. I’m too fucking delicate!

  2. christine

    Oh my god. I was so hoping you were going to say it was all a nightmare. You poor baby, and I mean that in the most loving way possible. I wish there was something I could do for you. Hope it’s just a 24 hour thing. :(

  3. Maggie

    Clearly, my day was not as bad as yours was (only could have been if I’d lived through 10.5, I’d guess), but if it helps, I’m guessing the reason they hooked you up to an IV is to keep you hydrated (that’s one of the biggest risks with food poisoning & cholera-like illnesses – that people vomit so much & lose so much fluid through diaherria that they get sick from dehydration. You were probably just getting saline & that was to keep you & Gabriella both healthy)
    I really hope you feel better. Keep your boys drinking lots of OJ and water. And you too. Whatever it is, liquids will only make it better.

  4. djmofo

    i know tony was pooing like a pooing machine but still..his ass should have driven you to the doc. you all could have had food poisoning. i hope you’re feeling better.

  5. yvonne

    He wanted to, he begged me to let him take me, I refused. I didn’t want to have to drag the kids out that early in the morning….

  6. theresa

    damn. i’ve had that illness twice, and its the worst illness ever. under no circumstances should your insides be leaving your body in two different directions at once. its just cruel and unusual punishment. and its not food poisoning, its some sort of virus. i can’t believe it took them that long to give you something to stop the throwing up though! the good news is that 24 hours later you feel 110% better. it looks like you’ve made it through the worst! hope you’re feeling better soon :)

  7. Stacey

    Well, I have a throat/ear/chest infection…so shitty.
    lost my blog, hosting is gone…so…shittier.
    Only thing good about today is the weather. And I can’t enjoy it. :

  8. myllissa

    Oh, Sweetie!! I wish I could fly out to Cali to care for you! That has to the worst. I’m sure you are hit the hardest by it because you are the mommy, the wife, you are VERY pregnant, yet VERY sick, and everyone will still look to you for comfort and care. I will keep you in my thoughts and prayers. Feel better real soon, honey!

  9. waistdog

    It’s a good thing you have TWO bathrooms.
    I’m sorry to hear about all this though, and hope you start feeling better soon.

Comments are closed.


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matt hutson

has been a member since Mar 2010 and goes by flashphoto.

I've taken all of these pictures and put them on here for all to view. Feel free to comment. All negative comments will be removed. If you don't like my pictures just move on. I say this because a few weeks ago someone decided to leave their two cents about some photos I posted. It's sad that people try put others down.

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33 responses

  • herman vandecauter

    herman vandecauter (Deleted) gave props (23 Jan 2009):

    Wonderful!! YES!!

  • James Walker

    James Walker said (28 Jan 2009):

    Really interesting photo, love it!

  • Detlef Rimkus

    Detlef Rimkus gave props (28 Jan 2009):

    beautiful capture, like the composition and lighting!!

  • whitney waddell

    whitney waddell (Deleted) said (31 Jan 2009):

    really interesting :)

  • F. Robert Openshaw

    F. Robert Openshaw   gave props (15 Feb 2009):

    A lovely and interesting effect.

  • Marie-Suzanne Nunes

    Marie-Suzanne Nunes said (18 Feb 2009):

    great composition and lighting!

  • lisa anderson

    lisa anderson gave props (18 Feb 2009):

    very nice photo.

  • matthias hilf

    matthias hilf gave props (18 Feb 2009):

    Superbly done !!

  • Olivier Scher

    Olivier Scher gave props (21 Feb 2009):

    very nice composition !

  • Wind Home

    Wind Home gave props (21 Feb 2009):

    Wow, this is great. Well seen photo.

  • John Dorosiewicz

    John Dorosiewicz gave props (21 Feb 2009):

    What wonderful light... ooooh!!

  • *Tim Needles

    *Tim Needles gave props (22 Feb 2009):

    Fantastic with great light

  • Rob Bowman

    Rob Bowman said (25 Feb 2009):

    Everything works so well in this image: color, lighting, and visual texture.

  • Cjor

    Cjor gave props (5 Mar 2009):

    Another nice photo, great lighting,

  • Craig Kilgore

    Craig Kilgore (Deleted) gave props (6 Apr 2009):

    Very cool concept and shot!

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  • Eric Sayah

    Eric Sayah gave props (12 May 2009):

  • Alejandro González

    Alejandro González gave props (19 May 2009):

    !!!!!!!!!!!!!!!!!!!!!!!!! absolut beauty !!!!!!!!!!!!!!!!!!!!!!!!!!!

  • M Daniel

    M Daniel gave props (27 May 2009):

    Everything is beautiful, colors, composition, everything

  • Ken McElroy

    Ken McElroy gave props (11 Jul 2009):

    So uniquely sensual - yikes, you've got an amazing eye.

  • Mojtaba Darvishi Cohan

    Mojtaba Darvishi Cohan gave props (12 Sep 2009):

    so nice shot

  • Chelsea Rising

    Chelsea Rising gave props (19 Sep 2009):

    Gorgeous! Voted :)!

  • Paul Lavallee

    Paul Lavallee gave props (28 Sep 2009):

    back to vote!

  • Lêda Nardelli

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  • John Linton

    John Linton gave props (10 Oct 2009):

    Oh YEAH! Rad!

    JOE FAILK gave props (20 Oct 2009):

    Yes it rocks!! Vote

  • Maraguetto

    Maraguetto gave props (29 Oct 2009):

    What to say after all these comments? Just voted.

  • Jean Pierre Vacherot

    Jean Pierre Vacherot (Deleted) gave props (9 Dec 2009):

    Nice voted

  • sasha ormond

    sasha ormond said (9 Dec 2009):

    this is really cool

  • Lori D'Ambrosio

    Lori D'Ambrosio gave props (20 Jan 2010):

    love the abstraction, the play of light and texture

  • Paulo Gama

    Paulo Gama gave props (9 Apr 2010):

    Awesome is the word.

  • Ann Janbay

    Ann Janbay said (28 May 2010):

    I'm out of words :-)

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Nas 1

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  • L W

    L W said (15 Jun 2009):

    I can dig this photo... Loving the green!

  • Sean Silva

    Sean Silva gave props (15 Jun 2009):

    Totally dig the photo. Great Shot

  • monica orozco

    monica orozco said (15 Jun 2009):

    digging it

  • Heidi Van Horne

    Heidi Van Horne said (15 Jun 2009):

    this is killer! nice work!

  • Kim Ussery

    Kim Ussery gave props (15 Jun 2009):

    man these colors are hoTT wolf... feeling the green light.... i give it a GO!!!

  • Lorenze Walker

    Lorenze Walker said (15 Jun 2009):

    This shot is DOPE... Keep it up!

  • Lorenze Walker

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    Def one of my faves here!

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  • Dmitri Robbins

    Dmitri Robbins said (16 Jun 2009):

    This photo SCREAMS green.

  • Kyle Bostian

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    love the composition, color, and contrast -- really conveys the energy and mood

  • Lou Davis

    Lou Davis said (16 Jun 2009):

    I'm envious... >;-{)}

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    eye4images gave props (16 Jun 2009):

    As allways (SW) SWEET WORK

  • Michael Brown

    Michael Brown said (17 Jun 2009):

    I looked through almost all of the photos submitted. There are some incredible shots. Incredible with respect to subject matter and artistry. This photo is a stand out. The colors, the capturing of the "action," and the layout are amazing.

  • barry

    barry gave props (17 Jun 2009):

    i'm wondering if he is wearing "pimp shoes" great shot!

  • Tommy Alastra

    Tommy Alastra gave props (17 Jun 2009):

    Awesome photo!

  • Learie Ford

    Learie Ford gave props (17 Jun 2009):

    Nice J-Dub

  • Deidre Jones

    Deidre Jones gave props (17 Jun 2009):

    Really Nice! That couldn't have been an accident!?

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    Lovin the Lolla...Holla!

  • Brian wise

    Brian wise gave props (18 Jun 2009):

    you've captured the real NAS. Hip-Hop is still kickin'

  • Brian wise

    Brian wise said (18 Jun 2009):

    Love this photo! Hip-Hop at its best!

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    Gotham Gang Green

  • gabe frankel

    gabe frankel gave props (19 Jun 2009):

    This is an awesome shot. Classic. J E T S Jets Jets Jets!!!

    AMBER LLOYD said (19 Jun 2009):

  • Adam Wolf

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  • Brian Basi

    Brian Basi (Deleted) gave props (16 Jan 2010):

    YES! The Rebel to America... awesome shot!!!

  • Amber Gregory

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    great color!

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Baby and Nikita

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© Kathryn Abercrombie
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: O o 0 o:

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rear entrance

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Sounds of Silence

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  • Donald Garrett

    Donald Garrett   gave props (15 Sep 2012):

    Looks a lot like my old piano from the early 60s. Good shot!

  • Davide Simone

    Davide Simone (Deleted) gave props (15 Sep 2012):

    Wonderful !!!!!!!!!!!!!!!

  • Kelly Nichols

    Kelly Nichols   gave props (15 Sep 2012):

    Great shot. Wondeful POV.

  • Ted Anderson

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    What a marvelous composition. I'm drawn right in.

  • Lynn E. Harvey

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    Drawn in as Ted said, but love all the textures, including on the base of the door! Fab!

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    Beautiful!Especially in B&W.

  • Andrea Silies

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    Wow this photograph says so much (aging, neglect, forgotten, etc.). What a great find and wonderfully captured

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Since we don’t have much of decorations yet in town, I decided to upload this one from my files.
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Last days of school

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Take the 2-minute tour ×
Mi Yodeya is a question and answer site for those who base their lives on Jewish law and tradition and anyone interested in learning more. It's 100% free, no registration required.

Some synagogues have a room for prayers that's used on a regular basis: weekdays, Shabasos, holidays. If there are two simultaneous minyanim, then one will be elsewhere, of course, but otherwise the main prayer room is always used.

Other synagogues have a main prayer room used on Shabasos, holidays, and on certain other occasions; on weekdays, however, prayers are held in a smaller room, often called the "chapel" or the "bes midrash", and the large prayer room goes unused.

Obviously, acoustics, demographics, and other pragmatics might influence whether a given synagogue is of the first type (described in the first paragraph) or of the second (described in the second paragraph). I am wondering whether there are also halachic or philosophical issues that affect this choice: do, for example, synagogues of the first type follow one halachic ruling or moral teaching, and those of the second type follow another?

share|improve this question
Often it is done out of practical, not philosophical considerations. Not to heat or air condition a large congregation when there are not that many people. –  Gershon Gold Dec 26 '11 at 18:35
@GershonGold, yes, I mentioned as much in my question, which then went on to ask whether there are halachic or philosophical considerations also. –  msh210 Dec 26 '11 at 18:55
The Fashion District shul in Manhattan is a nice example. For Yom Tov they actually have a large sanctuary, but for weekday they get just barely a minyan, so they use the small bais medrash. (7th and 40th st, north west corner). Conservative too I think. –  geoffc Dec 26 '11 at 19:25
Some shuls hold that everyone should come to minyan everyday, others hold that most people are patur from minyan during the week. –  Double AA Dec 26 '11 at 21:44
@DoubleAA, is that a joke? If not, a source please. –  Ze'ev Felsen Jan 27 '14 at 0:51

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Take the 2-minute tour ×
Mi Yodeya is a question and answer site for those who base their lives on Jewish law and tradition and anyone interested in learning more. It's 100% free, no registration required.

The question I am to ask is related to personal experience I've had but can be easily broadened. I am really asking for the sake of broadening my knowledge, and I apologize if any part of my question is offending as it is really not my intent.

As a non-jewish person, I have been asked by jewish people on Shabbat day to switch a water boiler on. The same thing happened to a friend, except he was asked to turn the lights on.

Although we both complied gracefully, I am wondering: is asking a non-Jew to perform such forbidden actions legal ? If so, how would things turn out in a society where everybody is a Jew and complies to the laws ?

I can't help but feel that either me doing what I did or them asking me to do them was somewhat unethical. However, I can also imagine that boiling water could be necessary for such urgent need as feeding a baby or tending to wounds. In such a case, does the law provide other workarounds ?

share|improve this question
Also see: Asking a Gentile for Air Condition on Shabbos –  yydl May 26 '11 at 0:18
Welcome to Judaism.SE, and thanks very much for bringing your question here! This concept is fodder for many popular misconceptions, so I really appreciate your giving the community a chance to write up useful explanations. –  Isaac Moses May 26 '11 at 1:36
Your excellent discourse has not answered the question of why should a non-Jew be doing things for a Jew if that Jew is forbidden to do such a thing in that said time. If an action cannot be done bu you, then you should do without the results of such action until such a time as it can be performed by you again. It seems to me that the religion cannot function independently of others who should make themselves available to perform such actions that are wrong for you to do. –  alice Apr 30 '12 at 1:00
@alice, indeed, the spirit of the rules described by jake's answer includes your point, but do note that there is a real distinction between "wrong for you" and objectively "wrong," even within one belief system, as explained in my answer. Also, note that unlike some other religions, Judaism does not have a goal of being practiced as such by everyone on the planet, so it has less need to "function independently." –  Isaac Moses Apr 30 '12 at 2:43

3 Answers 3

up vote 22 down vote accepted

There are many restrictions placed upon Jews on Shabbat that prevent them from doing even relatively simple things like switching on a light or heating up some food, etc.

Although biblically there is no prohibition against a non-Jew doing something for a Jew on Shabbat, to keep the spirit of Shabbat, and as a safeguard against violating it, the Sages prohibited a melacha (form of work prohibited on Shabbat) to be done by a non-Jew for a Jew on Shabbat.

However, this rabbinic prohibition is only violated if one of two things occurs:

  1. The Jew asks the non-Jew outright to do a melacha for him. This includes a command, request, significant gesture, or even answering "yes" if the non-Jew asks, "Do you want me to do such-and-such?"
  2. The Jew derives direct benefit from the melacha performed by the non-jew. This means that the benefit obtained by the Jew is a direct consequence of the melacha performed by the non-jew. This would not include, though, a melacha which removes an obstacle thereby allowing the Jew to derive benefit; that is called indirect benefit.

In order for the melacha done by the non-jew to be permissible, it must be done in a way which avoids both the above conditions. A classic example is to hint to a non-jew to turn off the light in a bedroom so that a Jew may sleep there by saying "The light was accidentally left on in my room. I will have trouble sleeping." There was no explicit command or request, so #1 is avoided, and turning off a light is considered indirect benefit, since it removes the obstacle (light) which prevented the Jew from deriving benefit (ability to sleep). So #2 is also avoided. Thus, this case is permitted.

However, if the non-Jew was asked to do so outright, or if he turned on a light in a room for the benefit of a Jew even without being asked at all, both of these cases are prohibited (by conditions #1 and #2 respectively), and the Jew may not derive benefit from the non-Jew's actions.

Two other important exceptions to this rule are:

  • A Jew may hint to a non-Jew to perform a melacha for the sake of a communal mitzva, even where direct benefit will be derived by the community. That is, even though #1 must still be avoided, #2 is not a problem. For example, one may hint to a non-Jew to turn on the lights in a synagogue for communal prayers even though turning on a light is considered direct benefit.
  • For the sake of a sick person, direct benefit may be derived from a melacha done by a non-Jew, though again, he may not be asked outright. [How "sick" a person has to be for this exception to apply is a matter of discussion, but it should be noted that there is no doubt that in the case of life threatening illnesses, no time should be wasted asking others to do melachos, rather a Jew is obligated to save the dying person by any means necessary.]
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Good write-up! Citations would round it out nicely. –  msh210 May 26 '11 at 2:35
@msh210, It's pretty much a summary of what I remember from reading R' Ribiat's 39 Melachos, Amira L'Akum chapter. –  jake May 26 '11 at 2:39
Thank you for the great explanation ! –  RaphaelSP May 26 '11 at 16:15
@jake - The Artscroll Sefer "Sanctity of Shabbos" AKA Hilchos Amirah L'AKUM is less stringent regarding certain aspects of this. IIRC, according to it, a Jew is allowed to ask a Gentile directly for something, if it is for a communal need. (Personal needs or wants are more complicated.) –  Adam Mosheh Aug 9 '12 at 12:08
With all due respect, I believe the Halacha is not quite like you said. Perhaps you want to check up your source. There are many times a non-Jew may be asked outright to do something; indeed, the main idea of Amira L'akum is when the non-Jew is asked outright. –  LN6595 Mar 2 at 4:17

To add just a little to jake's excellent explanation of the relevant Halachic rules:

It's important to remember that Jews are required to adhere to many commandments and restrictions that God set up to apply specifically to Jews. Roughly speaking, these particularistic commandments are not statements of universal ethics or morality; they're statements of God's particular mission for the Jews.

For example, regarding the Sabbath restrictions, God tells Moses (Exodus 31:13-17):

"And you, speak to the children of Israel and say: 'Only keep My Sabbaths! For it is a sign between Me and you for your generations, to know that I, the Lord, make you holy.

Therefore, keep the Sabbath, for it is a sacred thing for you. Those who desecrate it shall be put to death, for whoever performs work on it, that soul will be cut off from the midst of its people.

Six days work may be done, but on the seventh day is a Sabbath of complete rest, holy to the Lord; whoever performs work on the Sabbath day shall be put to death.'

Thus shall the children of Israel observe the Sabbath, to make the Sabbath throughout their generations as an everlasting covenant.

Between Me and the children of Israel, it is forever a sign that [in] six days The Lord created the heaven and the earth, and on the seventh day He ceased and rested."

It's clear from this language that the Sabbath represents a particular covenant between God and the Jewish people, which the Jews observe as a perpetual testimony to God as Creator. For whatever reason, God chose to only require the Jews to fill this role, not all of humanity. So, universally speaking, is doing work on the Sabbath day a bad thing? No. If you're subject to a covenant that forbids it, is doing it a bad thing then? Yes.

So, in these terms, your question boils down to "Is a Jew asking a gentile to perform acts that are forbidden for the Jew on the Sabbath compatible with the Jews' Sabbath covenant or not?" Intrinsically, there's no problem; the Jew's personal restraint in this situation fulfills the covenant. However, as jake explained in detail, the Rabbis eventually legislated additional restrictions so that Jews won't see their work getting done on the Sabbath and forget about their special role.

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Thanks for the additional explanation ! I'd accept both answers if I could... –  RaphaelSP May 26 '11 at 16:15
@RaphaelSP You're welcome! Thanks again for posing the question. Don't worry about the checkmark; I am so not in this for the points. –  Isaac Moses May 26 '11 at 16:17

There is a vital and simple set of rules I'd like to point out here. 1st, I assume a Gentile is either a family member (-in-law) or an invited guest. Such people should know about the traditional function of a Shabbos goy, even if only for the fun of it. I'm not sure I am clear about the situation presented in the original question....

As to that, I'd say any Gentile ought to be very vigilant, especially if the person is very close to the family. That Gentile ought to watch for necessities that Jews cannot perform should those necessities arise. Then the Gentile may do the action with ZERO prompting. If you followed my advice, well, out the window with rabbinical migraines!

A final note: any Jew not knowing what he's doing halachically needs to find the guidance of a rabbi, and FAST. It's one thing to be tangled up in a silly little matter of Law, but if you can't even handle Shabbos...well!

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Funding Opportunities: Week of September 18th

It’s time for the second installment of my funding series. I have found quite a few opportunities this week, particularly for doctoral students and those seeking short-term research fellowships.

Research Grants
Princeton Library Research Grants: Covers the costs of traveling to the library to conduct research using their collections.
Formby Research Fellowship: For research at Texas Tech’s special collections.
Truman-Kauffman Fellowship: For use of archival materials at the Truman library.
David Woodward Fellowship: For those interested in cartography; allows fellows to set up and curate a show or to research collections.
Verney Fellowship: For those researching Nantucket history.
Mark Samuels Lasner Fellowship: For researchers focused on printing history.

Dissertation and Early Career Funding
McNeil Center Dissertation Fellowship: For those studying early American history.
CLIR Mellon Fellowships: For dissertation research using original sources.
Newcombe Dissertation Fellowship: For those studying religion or ethics.
AABS Dissertation Fellowship: For those focused on Baltic studies.
Peter Rollins Travel Grant: For early career faculty travel to Popular Culture Association conference.
Bosanquet Bursary (UK): short-term residency in London for history or literature research.
Hench Post-Dissertation Fellowship: Offered through the American Antiquarian Society.

Other Funding Sources
EPA Graduate Fellowships: For those studying environmental science; includes one for Information Science.
Morningstar Public Librarian Support Award: To attend ALA Annual; for those engaged in business reference.
Collaborative Doctoral Awards (UK): Allows for research and work collaboration between academic and business.
Japanese Language Education Overseas (Japan): Opportunities to teach Japanese.
North Carolina Artists’ Fellowship: Helps creative development of artists and gives time to pursue work.
Getty Institute Grants and Fellowships: Short term fellowships, pre- and post-doctoral opportunities available.
Academy Professors: Academy of Finland recruiting full-time researchers who are considered prominent in their field.
Schoenecke Travel Grant: For graduate students to attend the Popular Culture Association conference.

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