AIDS & TRADITIONAL HEALERS IN NAMIBIA
Improving Collaboration between Traditional Healers and Biomedical Professionals
I. AIDS in Namibia
A. Situation Analysis
AIDS has become the greatest health threat to humanity in this century, having reached pandemic proportions with incidence rates in Africa higher than any other continent. The 1998 Namibian Ministry of Health and Social Services (MoHSS) HIV sentinel surveys indicate that the prevalence of AIDS is rising faster in Namibia than in any other country in Africa. In Namibia AIDS was first recorded in 1986 when four people were diagnosed HIV positive. Latest estimates of HIV prevalence for the Namibian population between ages 15 and 49 show a rate that exceeds 20%. Positive HIV tests have increased dramatically from 4 045 HIV-positive tests during 1988-92 to 53 330 cumulative HIV-positive tests in 1998.
Since 1996 AIDS has become the number one cause of death in Namibia. If the pandemic continues to spread at current rates, the number of people infected with HIV could reach over 400 000 by the year 2000. HIV/AIDS is still increasing with the highest prevalence being in urban areas and, secondarily, in rural areas close to roads.
A 1998 HIV sero-survey illustrates that HIV prevalence among pregnant women is still increasing in most areas. Rates in Windhoek among pregnant women were 23% with a high of 34% in Oshakati. Women make up 53% of all reported new HIV cases. In addition, HIV/AIDS strikes the economical productive age groups in the labour force.
Because of religious and cultural taboos about the open discussion of sex and related issues, parents and teachers are often afraid to provide youths with general and useful information about sex. A survey conducted at the Dawid Bezuidenhoudt High School in Windhoek shows that the only school authorities who had ever talked about sexual issues and teenage pregnancy were science teachers, but this was usually done in presentations of biological issues without discussing social and cultural factors. Students felt that the school could play a bigger role in preventing teenage pregnancy. School curricula materials and methods of teaching about AIDS have not yet been developed. Early sexual activity has contributed to the widespread presence of sexually transmitted diseases and 63% of reported HIV-positive cases in the age range 15-24 are female. The high incidence of teenage pregnancies also contributes to high fertility rates and encourages the spread of sexually transmitted diseases including HIV/AIDS. This high incidence rate is mainly due to lack of knowledge and uninformed attitudes among youths.
HIV/AIDS infection is a serious health problem for Namibia. The direct health care costs for HIV/AIDS infected individuals has been estimated at N$21.6 million in 1996. This was 2.9% of the total national health care budget. However, it is projected that by the year 2001 these direct medical costs could exceed N$380 million and could consume 20% of the national annual health care budget. Since Namibia has instituted a system of disability payments to victims of AIDS, it is estimated that by the year 2001, these payments could consume over 15% of the social services budget. However, direct medical and social services costs do not take into account the cost arising from loss of productivity, absenteeism at work, nor the costs to train and replace skilled individuals who have succumbed to the disease. These losses represent serious economic and social consequences for Namibia in terms of its human resource and developmental goals. The NACP has determined that it must expand its national response to the AIDS pandemic in an effort to best address all determinants of the pandemic to take into account current and future obstacles and opportunities related to fighting the disease. The NACP has stated that unless national awareness is improved and an appropriate response is mounted, it will be difficult for Namibia to avoid the devastating impact HIV/AIDS has had on other African countries.
B. Challenges and Opportunities
Due to the serious nature of the AIDS pandemic in Africa, modern health facilities in Namibia can not keep up with the treatment of AIDS and must resort to a Home Based Care Programme. With no cure in sight for AIDS, health promoters must look to other avenues for coping with the problem. As traditional healers are already in the communities practising health care provision, which includes the treatment of AIDS, it is only logical that traditional healers should be utilised in culturally appropriate programmes aimed at AIDS care, prevention and control.
Currently, traditional healers are one of the primary health care providers for AIDS patients. Historically, traditional healers have proven that they are proficient in the treatment of vomiting, diarrhoea and skin disorders, some of the primary complaints of AIDS patients. Traditional healers can be utilised in a Home Based Care Programme. In addition, traditional healers play an important role in counselling victims of AIDS and their families, as well as providing traditional purification which allow victims to be re-integrated and accepted by their communities.
Traditional healers have been successfully trained and utilised for AIDS control and prevention campaigns in many African countries. Namibia's potential for utilising this currently untapped resource is as great or greater than other countries in southern Africa. Namibia has a small population and a relatively high number of traditional healers; approximately 2500 are currently registered with the Namibia Eagle Traditional Healers' Association (NETHA). Through current research on utilisation patterns for alternative health care systems in Katutura (Namibia's largest African township), it is estimated that utilisation rates of traditional healers in the urban areas could be as high as 70% of the African population and possibly even higher in the rural areas. With such a high utilisation rate for traditional healers, it becomes clear that AIDS patients are already accessing this informal health care network. It would further benefit the Namibian nation if a collaborative effort could be devised in which biomedical professionals and traditional healers combine and coordinate their efforts in the fight against AIDS.
II. Project Overview
A. Project Collaboration: The Florence R. Kluckhohn Center and Perception
The Florence R. Kluckhohn Center is a nongovernmental organisation that conducts intercultural and cross-cultural workshops designed to improve understanding within and between diverse cultural groups and communities. This workshop process was originally developed by Dr. Kluckhohn as part of the Harvard Values Project. Operating with a core group of Associate Scholars located around the world, the Center bases its work on the premise that many conflicts and misunderstandings between groups and cultures are rooted in different ways of perceiving and interpreting the world; therefore, any effort to design culturally appropriate programmes or resolve conflicts and promote cooperation within or between groups should begin with an understanding of how variations in basic values and perceptions influence behaviour and communication.
The Kluckhohn Centers methods have been used in the design of health delivery systems, family counseling, community and economic development, natural resource management, multicultural education, conflict resolution and organisational development. The Center has a long history of working with indigenous peoples and governments. Since 1987, the Center and its Associate Scholars have conducted projects with indigenous peoples in Mexico, Brazil, Peru, Bolivia, Chile, Guyana, Guatemala, South Africa, New Zealand and Canada, as well as within the United States among tribal communities, colleges and universities, public and private sector groups, and federal agencies such as the U.S. Forest Service, the U.S. Department of Agriculture, and the U.S. Environmental Protection Agency. The average cost of a Kluckhohn workshop operating in the United States is
US$ 30 000.
Perception is a nongovernmental organisation whose mission is to promote perceptual, cultural, and biological diversity. Its president, Dr. Lumpkin, previously worked for the Kluckhohn Center as Project Development Officer and also conducted one of the first assessments of traditional healers and community use of traditional medicine in Namibia for UNICEF and the MoHSS from 1993-94. The Kluckhohn Center will be the lead agency in this project and Perception will take a secondary support role.
B. Intercultural Communication and Planning Methodology
A centrepiece of the proposed project will be the Intercultural Communication and Planning Methodology, a variation on the original Kluckhohn workshop. We believe that the issue of improving understanding and collaboration between traditional healers and biomedical professionals is one that is well-suited for the use of this methodology.
Experience has shown that use of this method provides participating groups and communities with tools, insights, and understanding that open up new patterns of communication, providing a foundation for more enduring solutions to common problems. This is critically important in understanding what AIDS means to the various stakeholder groups. Each of the groups faces a common problem: the AIDS crisis. What varies are their perspectives on the disease and how they believe it should be confronted. An additional factor is how the various stakeholders perceive each other. This situation is parallel to the situation faced in many other training programmes undertaken by the Kluckhohn Center utilising this methodology. In each instance, the method provided the groups with new and valuable information about themselves and how they were similar and different in such areas as: the meaning of change, progress and tradition; how decisions should be made, and by whom; the relationship between team building and community accountability; their perspectives on the efficacy of new knowledge in relationship to traditional teachings; and how they define meaningful and measurable outcomes. Discussion among the stakeholders on these and other issues is likely to result in greater appreciation for how and why they differ in their understanding of the AIDS issue, while, at the same time, shattering previously held stereotypes that are barriers to true communication. As with other groups that have participated in these workshops and training, they will uncover unexpected common ground upon which they can build collaborative strategies for dealing with AIDS, strategies that respond to and respect the differences between them.
There is an additional factor that seems appropriate to the use of this methodology for the issues of AIDS health care in Namibia: the methodology integrates into its process the fact that, in addition to differences between and within cultures, the institutional values of organisations that serve cultural communities may differ in important ways with those of their clientele. The methodology provides a tool for these groups to understand how, and to what degree, stereotypes and variations in basic values and perceptions influence relations between them. Just as importantly, the process applies these understandings in a manner that benefits communities by enhancing the responsiveness of the institutions that serve them.
2. Project Outcomes
It is envisioned that the project will have the following outcomes:
improved understanding by traditional healers of AIDS and its treatment;
improved understanding by biomedical professionals of the methods used by traditional healers;
enhanced collaboration among traditional healers and biomedical professionals in dealing with AIDS;
recommendations and plan of action for enhanced program effectiveness, including a working group which will continue the process;
a trained local facilitator in the methodology.
Prior to the start of the workshop, all participants will complete a brief questionnaire on issues relating to AIDS and its treatment. A similar questionnaire will also be completed at the end of the workshop to assess the impact of the workshop, as well as to identify areas where gaps remain. This questionnaire also will be used as a tool for monitoring and evaluation of the Kluckhohn workshop.
III. Project Components
The components of the Intercultural Communication and Planning workshop for traditional healers and biomedical professionals (listed below) are designed to work interactively to: 1) enhance the workshop experience, 2) broaden awareness and understanding of the issues involved, 3) facilitate recommendations for improvement of the programme, and 4) initiate a process for collaboration.
Prior to arrival of the workshop team, Dr. LeBeau (who resides in Namibia) in consultation with agency counterparts, will have 1) identified appropriate participants and language translators, 2) arranged for translations of materials as necessary, 3) obtained agreement on logistical arrangements, and 4) conducted the pre-workshop participant survey to be used later to monitor and evaluate the impact of the workshops. The workshop team in the U.S. (Dr. Lumpkin and Mr. Russo) will have prepared all other materials and will have coordinated preparation with Dr. LeBeau. The workshop will include a minimum of 30 and a maximum of 40 participants evenly divided between biomedical health professional and traditional healers.
As part of the intercultural communication and planning methodology, two types of interviews are used: 1) the perceptual diversity survey and 2) the issue-oriented knowledge, attitudes, beliefs, and practices interviews. Together these measure quantitatively and qualitatively how people perceive both the world around them and specific critical issues, such as AIDS.
The perceptual diversity survey focuses on four primary dimensions: 1) time, 2) relationship to nature, 3) social relationships, and 4) activity. These indicators provide us with a perceptual map of each person interviewed, and, when all the interviews have been administered, with a general perceptual map of each group or culture. These indicators also allow the group to explore a dimension we call Self and Other which deals with the stereotypes that one group applies to the other. The perceptual diversity survey involves one-on-one, oral interviews in which the interviewer notes body language, concerns, pauses, worries, and any other signals that can serve as additional information to help explain how the interviewed person perceives the world.
The issue-oriented survey uses structured, open-ended interviews. These are conducted among the participating groups and delve into knowledge, attitudes, beliefs and practices surrounding the issue of critical concern. The surveys will be conducted prior to the workshop.
The data from the perceptual diversity surveys are then compiled and subjected to rigorous statistical analysis. The statistical analysis is followed by pattern analysis. This process provides a profile of 1) dominant and subsidiary values and perceptions, and 2) the nature and range of perceptual diversity within and between the participating groups. Attention is also directed to how well these similarities and differences are understood by the groups and their communities. This descriptive analysis provides valuable insights into how variations in values and perceptions influence communication between the groups and how the groups can overcome barriers to cooperation.
This analysis becomes a reference point for the workshops focus on understanding perceptual differences. Because each workshop and its groups are unique, the final workshop design is determined only after all the data have been thoroughly analysed. In this way, the design of the workshop responds to the core values and perceptions of the participating groups and their communities.
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