How to tackle AIDS - Part 2 | Dr Gunnar Holmgren

Concluding his article from last month, Dr. Holmgren details parallels of behaviour change in other social areas.

The best examples of sustainable changes of large population groups come from grass-roots movements. These have often used all available channels, such as the power of small groups and peer pressure to convince people about the value of behaviour change.
This was certainly true in Sweden in the temperance movements of the mid-19th century, where whole communities were being destroyed by an unparalleled level of alcoholism. It is estimated that in Stockholm at this time, the consumption of alcohol was equivalent to 50 litres of brandy per person per year, with each man drinking one third of a litre per day on average! The medical effects of alcoholism were horrifying.
My wife's family had a 'black sheep' in the family some generations back who had a severe alcohol problem. His family were literally dying of starvation due to his squandering of the family's money on alcohol. His wife had given birth to twins and one night he came home from the pub to find his wife dead and the twins still trying to suck the last few drops from her breasts. In his alcoholic haze, he found this scene amusing and returned to the pub to relate this to his friends as a huge joke. His friends were shocked by his callousness and the scandal of his behaviour caused such an outcry in the village that the whole community got involved in the temperance movement. A generation of the family became temperance enthusiasts.

Grass-roots movements

What typified the Swedish temperance movement was how all groups at the grass-roots level joined together e.g. sports groups, trade unions, religious groups and cultural associations. The threat at this time was so tangible that it lead to a veritable forest of temperance movements, each with a different philosophy but all committed to changing a very menacing situation.
There are significant parallels between the alcohol menace in Sweden in the 19th century and the AIDS situation in many countries today.

* Both are related to a form of behaviour which within defined limits is associated with pleasure and little risk, but when the behaviour takes on the characteristics of an addiction, it becomes subject to the law of limited returns.

* Both are associated with rapid social changes that lead to a loss of the stable environment.

* Both are much more common in situations of poverty, high unemployment, breakdown in family structures and the commercial exploitation of human weakness for profit.

If the result of polarisation between 'moralisers' and the 'public health fundamentalists' leads to their spending much of their energy on in-fighting, then it could weaken the whole effect of containing the AIDS epidemic. But if each group recognised the limitations within the one-track philosophy on both sides of the divide, then a synthesis of the best features of the two approaches could be very fruitful in stemming the tide of the virus's spread.
Of significant interest is the recent finding that the two 'addictions' (i.e. alcohol and unrestrained sexual behaviour) are linked, not only in behaviour patterns, but alcohol even increases the permeability of the mucous membrane barrier to the virus. It also speeds up the rate at which HIV infection goes over to AIDS.
It is time we woke up to the potential in grass-roots movements and their capacity for themselves seeing where the danger lies, what to do about it and using their unique capacity for bringing about sustainable behaviour change from within. This will involve peer pressure, being given the scope to decide on their own priorities, which may not always correspond to the accepted wisdom of the international activists, and interfering as little as possible with a viable movement that is bringing about behaviour change with reduction of HIV transmission. It is noticeable how the itch to interfere from outside is still a feature of most Western experts.
Three examples of such grass-roots movements in Africa have brought about impressive behaviour changes.

Home, not hospital

The first grew out of a pioneer approach started by a Salvation Army hospital at Chikankata in Zambia. When the AIDS epidemic reached them in the middle of the 1980s, they quickly realised that hospital-based care for the growing number of patients was against the wishes of the patients and their families, as well as being unrealistic in a situation of limited resources. Once the diagnosis of AIDS or an HIV-related disease had been made, most patients wanted to go home and continue healthcare there if possible. This Home-Based-Care initiative became a major new approach with many advantages for patients, their families and even for the health sector.
A counselling 'cascade' was established, whereby first the patient was counselled alone about the diagnosis and its implication for the future. Pastoral and counselling care was available for all who wished to have an open dialogue with a pastor/counsellor about the deeper dimensions of this crisis. Then, with the patient's permission, the whole extended family who could be gathered were counselled as a group. The counsellor showed the family what the diagnosis would mean for them as a family, how they could feel safe in normal, social contact with the patient, and most significantly how they could protect themselves from being infected in other contacts. At the time for going home, with the family's permission, the whole village was counselled about the crisis that had befallen one of them.
This occasion turned out to be an unparalleled opportunity for a group discussion about how to give support to a patient, and what behaviour changes that might be necessary for them to remain uninfected. Sometimes the decision of the village was to call a Christian pastor or health worker to give specific advice about how to change high-risk behaviour.
Often, the village counselling led to an even wider community counselling, whereby several villages would come together to make decisions about changing major cultural patterns of behaviour. An example of this is a custom that is prominent in the local tribe, termed 'ritual cleansing'. When a person dies, the spouse has to be 'cleansed' after the death by having sexual intercourse with a sibling of the deceased before there is any possibility of remarriage. After community counselling, a number of groups made the decision that 'ritual cleansing' by sexual means would henceforth be prohibited and alternative methods of 'cleansing' by non-sexual means would be recommended. These methods were fully acceptable in the old culture but had hardly been practised previously.
The end result of this AIDS campaign was shown by two indicators: a decreased rate of pregnancies in schoolgirls, and a decreased rate of cases relating to adultery before the local courts.
Besides strengthening family relationships, the community counselling has sometimes had the effect of uniting communities previously divided.

Promises

The second movement started in a secondary school in Lusaka, Zambia, when a group of students were discussing the AIDS epidemic and suddenly came to the realisation that every one of them had a close relative who was either dying or had died of AIDS. The threat became so tangible that it led to them starting an anti-AIDS club. They decided that to become a member a student had to make three promises:

1. To avoid HIV infection and AIDS by avoiding sex before marriage or outside marriage.

2. To help my friends and relatives to protect themselves by telling them about HIV and AIDS.

3. To help people with HIV infection and AIDS as much as possible.

This movement has interesting parallels with the promises of the temperance movement in Sweden in the last century. In both movements, grassroots people's organisations, both religious and secular, have been prominent.
The anti-AIDS club movement has spread like wildfire such that 1,500 schools in the country have clubs. They are linked by a magazine, and a local general practitioner, Kristi Baker, has been central in producing pamphlets for the movement for use by primary, secondary and post-secondary students. A wealth of promotional material (games, T-shirts, posters and stickers) have been produced. Plays have been written and produced, songs have been composed, lectures, discussion groups, marches and many other activities have been organised to raise the level of awareness and to promote a no-risk lifestyle.
Evidence of the impact of this movement shows in a decreased rate of pregnancies in schoolgirls where the school has a club, and in lower HIV-seropositivity in blood donors from these schools.

Positive morality

A third movement originates from the Lutheran churches in Tanzania, where an extremely energetic church-related campaign has made an impact in some of the worst affected areas. The message is absolutely clear: only a lifestyle consistent with stable family relationships will reduce the level of the spread of the virus. Morality is presented in an open, positive way without the negative, destructive 'moralism' that has often closed the minds of those most needing to hear the message.
Evidence of this movement's impact has shown itself in decreasing levels of HIV positivity in blood donors at the hospitals, decreased levels of HIV in couples coming for pre-marriage testing, and decreased levels in patients coming to hospitals with illnesses where HIV infection could be suspected. Some other sexually transmitted diseases have decreased significantly.
Certain common characteristics are seen in these and several other successful interventions:

1. All are true grass-roots movements with the power of decision-making at the community level. All have help from outside but without taking away local independence.

2. All are in response to an actual (not theoretical) danger.

3. In all of them, there is a central role of 'peer pressure' to initiate and maintain behaviour control.

4. Most use spiritual terms to bring about this change.

5. None of these groups depend on the technical fixes that we in the West are so fond of (e.g. to see condoms alone as the answer. These are seen as one of a number of measures that may be needed, but by no means the only or even the most important intervention. The local community will have to decide the right mix of interventions to be introduced).

6. Most present traditional conservative views of sexuality and strengthen some of the old cultural control mechanisms that existed in many African tribes.

7. All have a very supportive attitude towards HIV/AIDS patients.

8. All strengthen stable family relationships and discourage pre-marital sexual intercourse.

9. All go against the well-known trends in current teaching in the West, as typified by the Swedish AIDS delegation.

There is a real glimmer of hope in AIDS campaigns in many parts of Africa, and it is very much in line with the cultural norms that existed in many tribal communities in Africa prior to urbanisation and the influence of Western culture. In many of these traditional communities there are repositories of wisdom and knowledge that we ignore to our detriment.
One feels sympathy with the words of T.S. Eliot: 'Where is the life we have lost in living? Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?'

Dr. Gunnar Holmgren, MRCP, DTM&H, is a consultant in International Health Care and HIV/AIDS. He was a missionary doctor at a Swedish Baptist Mission for many years in Zambia, and is now back in Sweden.

How to tackle AIDS - Part 2

Initiatives used as grassroots level in Africa to reduce the incidence of AIDS in the population