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Development

for
Health

Selected articles from Development in Practice


Introduced by Eleanor Hill

A Development in Practice Reader


Series Editor: Deborah Eade

Oxfam (UK and Ireland)


Published by Oxf am (UK and Ireland)
First published 1997

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Contents
Preface
Debozah Eade 4

Over the edge: health-care provision, development, and marginalisation


Eleanor Hill 6

Research on women's health: some methodological issues


T.K. Sundari Ravindian 14

Deterrents to immunisation in Somalia: a survey of mothers' attitudes


Anne LaFond 23

Participatory appraisal in the UK urban health sector: keeping faith with perceived needs
Teresa Cresswell 31

Stressed, depressed, or bewitched? A perspective on mental health, culture, and religion


Vikram Patel, fane Mutambirwa, and Sekai Nhiwatiwa 40

Training indigenous workers in mental-health care


Jane Shackman and Jill Reynolds 49

The psychosocial effects of conflict in the Third World


Derek Summerfield 58

Financing primary health care: an NGO perspective


Patricia Diskett and Patricia Nickson 73

Population control in the new world order


Betsy Hartmann 80

Adjusting health care: the case of Nicaragua


Centro de Informacion y Servicios de Asesoria en Salud (CISAS) 86

Evaluating HTV/AIDS programmes


Hilary Hughes 90

Widows' and orphans' property disputes: the impact of ADDS in Rakai District, Uganda
Chris Roys 94

Annotated bibliography 100


Research projects and relevant organisations 107
Addresses of publishers and other organisations 110
Preface
Deborah Eade

Health and well-being are deeply personal when people are already dealing with
matters. Nothing is more intimate than the poverty, and what this means for their
experience of conceiving and bearing a child, health status. At one end of the spectrum,
and giving birth to a unique human being; we see the importance of the macro-
none of us can live another's fear or pain; and economic and ideological settings.
death itself is something we cannot share, Economic policies that result in the under-
however real the grief we suffer. And yet it is funding of public services and the
precisely when we or those close to us face fragmentation of the regulatory role of
illness or chronic suffering that we perceive government tend to reduce the threshold of
that health is in reality a very public issue. what is considered an acceptable minimum
Policies which dictate what level of health- standard of health-care provision for the
care provision is guaranteed, what kinds of population at large. Access to health care
service will be offered, how priorities are becomes dependent on the individual's
established between competing claims, capacity to pay: patients are turned from
where resources are concentrated, and what citizens who have rights and responsibilities
alternatives are available all become far into clients or consumers who can (if they
more immediate when they affect us or our can afford it, and if anyone will insure them)
loved ones. Facing a particular health- take their custom elsewhere. The question
related condition, and then being on the of financing health care may thus be posed
receiving end of the decisions or prejudices as a pseudo-technical one: what kinds of
of others be they health professionals, cost-recovery and insurance mechanism
religious authorities, family members, 'work', and in what circumstances? The goal
neighbours, employers, or insurance of 'Health for All by the Year 2000' is eroded
companies is something that often gives into one of 'health for those who can pay
us a new awareness of how limited is our today'.
capacity to control some of the most central
In seeking to harmonise market forces
aspects of our lives. It gives us an insight
with people's health and well-being, we risk
into what exclusion feels like.
overlooking the underlying question of
Disempowerment and exclusion are whether health can or should be treated as a
caused by a similar combination of personal commodity. The figures are grim. During
experience and circumstances on the one the 1980s, the number of people living in
hand and the social and political context on absolute poverty rose to over one billion,
the other. The essays collected here show with the gap in per capita income between
some of the complex ways and levels on the industrial and developing worlds
which such exclusion operates, especially growing threefold between 1960 and 1993.
Preface 5

Each year, over 12 million children die of ways in which disempowerment disables
preventable causes before they reach individuals and communities, the authors of
adolescence. Average life expectancy in the the essays gathered here share their own
richest countries is expected to rise to 79 practical experience of enabling people to
years by the turn of the century; while it is develop the skills and the confidence to
expected actually to fall to 42 years in some survive adversity, and to shape development
of the poorest.1 It is a commonplace to say in ways that better address their health-
that poverty and ill health are mutually related needs.
reinforcing. And yet current trends suggest The papers in this volume illustrate the
that 'the enjoyment of the highest attainable issues addressed by Eleanor Hill in her
standard of health' which WHO describes as introductory overview: how and why it is
'one of the fundamental rights of every that people or aspects of health care are
human being' is seen almost as a by-product, pushed to (or left in) the margins. They
something that will trickle down to the illustrate also her contention that it is often
bottom some time in the future. There is a at these margins that ground-breaking
long way to trickle before this fundamental (though unspectacular) achievements are
right reaches those who are destitute made. Building on the insights of those who
(currently one fifth of the human race), those do not have power and status, and who lack
who survive precariously in the informal many of the means to nurture their own
sector, or those whose access to health care health, reveals far more than the statistics
is limited by their age or their disabilities, or can tell us about what is needed to ensure
by armed conflict. And while seven out of
that development is for health and about
ten of the world's poorest people are female,
the consequences for humanity in failing to
women's health needs are widely neglected,
meet this challenge.
whatever their background. Yet, if develop-
ment is not for health, what is it for and
Deborah Eade
who can expect to enjoy it?
Editor, Development in Practice
Several essays in this compilation from
Development in Practice examine the issue
of exclusion from this angle. What are the Notes
forces that prevent women and men from
taking advantage of the health services that 1 Figures taken from The World Health
are, theoretically, there for their benefit? Report 1995: Bridging the Gap (Geneva:
Often the answers lie in the inappropriate WHO); and Human Development Report
ways in which such services are offered: 1996 (Oxford and New York: UNDP).
expecting results too soon, ignoring other
forms of knowledge and belief systems,
imposing an agenda from above or outside,
or failing to understand the complex social
and power relations that affect people's
behaviour and their expectations. A woman
may have a right to ante-natal care, but if she
does not know about it or why it matters, or
if she cannot attend (whether because
clinics are held at inconvenient times or
inaccessible places, or because other family
members do not allow her to go), then she
may show up as a 'failure' in the midwife's
performance. Exploring the many subtle
Over the edge:
health-care provision, development, and marginalisation

Eleanor Hill
'Health' is a broad subject. It involves canvas to cover, as the nature of these margins
anything from high-technology heart differs from one context to another, but it is
surgery to the simplest of home remedies for at the margins that needs are most likely to
the common cold. The conditions and be most acute, as well as most often over-
people dealt with by health practitioners looked. It is also at the margins that we often
also cover an enormous range: from find the most interesting and exciting work,
compound fractures to schizophrenia; from the most challenging views. And it is by
infectious disease to alcoholism; from moving out to the margins that we can look
sufferers of arthritis to sufferers of torture. back at the whole field and see what remains
The context within which health care is to be dealt with which is currently neglected.'
provided varies across a number of dimen- An example of the way in which a
sions: from centralised, government- marginal situation can be liberating was
controlled provision of a service which must shared with me by a colleague who worked
cover an entire nation to small-scale private- in Angola throughout the civil war. He had
sector provision either for profit or on a been responsible for a hospital and a number
charitable basis, with all gradations in of satellite facilities. The central hospital
between; from professionally trained directed and controlled work for the entire
practitioners to provision of care in the programme, with little devolution of authority
home by family members. This is without to staff at the periphery. As the war
the common distinctions of curative and progressed, infrastructure deteriorated and
preventative care, of public or community travel between facilities became increasing-
health and personal clinical requirements. ly dangerous; gradually the old system
became untenable. In order to keep facilities
operational, it was necessary to allow them
individual control of their programmes,
Health at the margins priorities, and activities. Despite the persistent
The challenge is to find a way of addressing problems of working in a context of armed
the topic from a clear perspective without conflict, this decentralisation allowed staff
losing sight of the need to deal with its to continue to provide a health service, with
complexity. The more I thought about the positive effects on their morale.
nature of Development in Practice as a journal Within this example it is easy to see how
and the working context of its readers, the the definitions of what is central and what is
more it seemed appropriate to focus on marginal can alter very quickly as a
health and health-care provision at the situation evolves. Peripheral staff and
margins. Even this leaves me with a broad facilities who were of little relevance in
Over the edge 7

decision-making or policy-development their lives. In short, we must enter into the


become central figures as the locus of control real complexity of each situation to discover
alters. At the same time, the central facility where its margins are and who operates at
of the hospital and its management become these margins. It is this which presents the
somewhat marginal to the everyday opera- most exciting and most difficult challenge, as
tion of the system as a whole. Within the it constantly confronts us with the assump-
new context, other margins would become tions we make and the stereotypes we con-
evident and claim attention. This changing struct, demanding that we reconsider over and
nature of the margins in relation to health over again how we make sense of the world.
and health-care provision means that it is Another anecdote may help to illustrate
essential to keep analysing and reviewing this. I remember watching a TV document-
any situation. Focusing on the margins ary about the Maasai in East Africa, featur-
helps us to avoid complacency through this ing a ritual through which women could
constant requirement for re-analysis. overcome infertility. As the programme
went on, it appeared to me that these
women, for whom infertility is an extreme
misfortune, were entirely without power
Where do the margins lie? and destined to remain at the margins of
How to define the margins? One of the their community. Without children as proof
simplest means is to begin with those areas of their value to the community, they were
where health is poorest and explore the way of little consequence, and even this small
in which the situation of the people may be chance of altering their plight was to be
considered marginal. The first characteristic denied them. But just as I was reaching a
to spring to mind is that very often they are point of equal sadness and anger on their
at the margins of prosperity, surviving with behalf, the position changed. An older woman
a minimum of resources. Physical marginal- counselled the younger ones who needed the
isation is another common feature. People ritual to threaten the men with tears if they
may be many miles or hours distant from did not oblige in preparing for the ceremony.
the centres of provision, prevented from To an outsider this seemed an idle threat, of
reaching them by rough terrain or poor no particular consequence: women's tears
transportation systems. In addition they are are a frequent enough occurrence, but they
often distant or marginal in a cultural and do not often seem to bring dramatic change.
political sense, not belonging to the groups In this context, however, the threat of them
who hold power, speaking a minority language, was sufficient. Power can be exercised in
or simply accorded no importance within many ways, some of them unexpected and
the political decision-making process. unrealised, and it is this which defines who
counts as central and who counts as
This pattern of marginalisation persists at
marginal within any specific setting.
both macro and micro levels, creating over-
lapping layers of exclusion. It is of course
easy to generalise, to designate particular
groups as marginalised and then focus atten-
tion on them as the most needy. An instant
The margins within the health
list is easy to construct: women, children,
service
the elderly, the mentally and physically It is not only the general population who can
disabled, the displaced. But it is vital also to be marginalised in this way. The same is
consider the ways in which people overcome often true of those who are charged with
or overturn such situations, how they manage providing them with health care. Practi-
despite all expectations to maintain some tioners too may be struggling to operate
control and a central position in aspects of with few resources, in a context where the
8 Development for Health

bulk of a budget is spent on maintaining especially in the remote rural areas where
central facilities. They may be isolated from provision has always been problematic.
professional discourse and discussion, from They issue orders that committees must be
the latest ideas and technology. In fact they formed, action plans drawn up, and local
often suffer a double marginalisation, for in budgets prepared and submitted, all with the
addition to this professional isolation, they full participation of the local community.
may well be isolated from the population The local health worker is naturally a little
around them. This separation has educa- apprehensive. Her initial training did not
tional, cultural, and psychosocial dimen- prepare her for this, and the few brief in-
sions, as all these factors operate to create service sessions since she qualified are not
distance between the professionally trained enough to instil confidence. Besides which,
health practitioner and the lay population. she does not believe that the local commun-
This distance may be expected by those such ity understands health issues properly. They
as myself when choosing to work in a never appear to take notice of her educational
completely different culture, but it is just as sessions, persisting in drawing water from the
acute when one is working within one's own river. The communal latrines remain unused.
culture. I have been forcibly struck in the How can she trust them to make decisions
past by how little I knew of the realities of concerning health care? And who will get
living on State benefit, or of surviving in a the blame if the monthly statistics show a
violent domestic situation; yet these are the deterioration in the health of the commun-
realities for many of the women I met as a ity? She will. The result is that she feels
working midwife. alienated from the community and aband-
In a very real sense a health service can be oned and betrayed by the health service.
viewed in the same way as any other com- Counteracting this marginalisation within
munity with similar distribution patterns of the health service is a difficult but crucial
power and control. It can be hard for those task, in which initial and on-going training
working on the periphery to believe in their are fundamental. Keeping curricula up to
own capacity to take decisions or alter date in a rapidly changing world is not easy.
policy. Large bureaucratic institutions such Once trained, many health workers have no
as ministries of health do not lend them- further contact with their training institu-
selves to flexible working practices. In many tions and continue to work according to
cases the training of health workers discour- their original instruction. Others are desper-
ages them from showing too much initiative. ate to advance their knowledge and skills,
Safety lies in following the prescribed proced- but face daunting barriers: funding is hard to
ures, carrying out tasks exactly as specified, acquire, study leave is rarely granted, family
and filling out the required reports to show commitments can make it impossible for
that this is being done. This is perhaps them to travel for studies.
especially true of non-medical staff, upon
whom much of the burden of caring falls in
developing countries. Yet it can be these Changing policy priorities
same staff who are expected to encourage the
community to become active and participate Another important way in which marginali-
in decisions regarding health-care provision. sation occurs is through the changing
The following illustration is not unusual. priorities of health-care practitioners and
For a range of reasons (international press- policy-makers. The direction of the endeav-
ure, budgetary constraints, political insecur- our of health professionals can be deeply
ity), policy-makers decide that increased affected by the current fashions within these
community participation is required to professions, not only by determining which
improve the efficiency of the health service, specific conditions receive the attention of
Over the edge 9

research teams, but also in terms of the of their patients. Bedside manner was no
approach followed in planning and longer crucial, so long as the patient took the
delivering services. It is interesting to look medicine and followed the doctor's orders,
back over the way this has differed through for the 'doctor knew best'. The era of the 'pill
time and differing political contexts. for every ill' began with great promise, but
As with most aspects of human society, the result was to increase the knowledge gap
understanding of and attitudes towards between practitioners and their clients. This
health and illness have altered over time. brought a startling change to the balance of
Before the twentieth century, the common- power and control: the health worker,
est response to ill health was a pragmatic especially the medical practitioner, began to
one of symptomatic care, rather than cure. assume a very central position. Other actors,
Among much of the world's population this family and community members, were
remains the predominant pattern. Certain pushed out to the margins, their influence
well-known conditions may be deemed undermined by the new advances.
curable, but otherwise practitioners provide A gradual sense of disenchantment and
support and encouragement while the frustration set in as the limitations of
natural healing process occurs and (it is scientific medicine became clearer: resistant
hoped) resolves the problem. Remedies have strains of infectious agents; adverse reac-
often been tested through generations, but tions to drugs,- the failure to resolve
may also have arisen through idiosyncratic common and urgent problems. While the
individual belief. The priority among health doctor might know best, he or she did not
practitioners is to provide emotional seem to know enough. Eventually this led to
support and physical care, with an emphasis a thorough review of health-care provision
on the development of a good 'bedside and the optimum mechanism for achieving
manner' which will inspire confidence and good health across the whole population.
so help healing. If death results, the humanity While high-technology medicine had claimed
of the practitioner may be important in centre-stage with its dramatic gains, the
helping the bereaved to come to terms with failure to address other issues remained a
their loss. Within this framework, the serious concern. The eradication of small-
health worker is a rather marginal figure, of pox proved to be a peak of achievement
limited potency. The support obtained from which has not since been matched. Malaria,
family and social networks is a much more diarrhoea, pneumonia, and malnutrition all
central consideration. Health, illness, and continued to take a high toll of human life.
death are woven into the fabric of everyday Attention turned to the need to expand health
life, and most individuals have a role to play care beyond the limitations of the medical
in their maintenance or prevention. Ritual model, as changing perspectives brought
and ceremony are important in regulating different issues to the centre of the debate.
the emotional burden which accompanies
Primary Health Care, as envisaged at the
disease and death, placing those who per-
1978 Alma Ata conference, attempted to re-
form these services in a prominent position.
orient the provision of health care towards
More recently the allopathic medical an holistic, preventative approach.2 It
approach became prevalent. Advances in the stressed the social, economic, and political
understanding of pathology and disease aspects of health and disease, emphasising
transmission, coupled with those in physical the need for inter-sectoral work and collab-
and biological sciences, provided spectacu- oration. This was an effort to expand the
lar cures for a wide range of conditions. Here focus and responsibility for health from the
the practitioners' desire was to display their medical professions to a far broader base, to
mastery of disease and its treatment, perhaps some degree returning to an aspect of earlier
in the face of ignorance and doubt on the part times in which care and cure were obtained
10 Development for Health

locally from personally known practition- this. Health practitioners have learned skills
ers. Given the radical nature of this reorient- in group dynamics, conflict resolution, team
ation, it is not surprising that it met with building, and community development in
resistance and proved to be a much more order that they may foster effective partici-
complex task than was initially realised. pation. At the local level in a large variety of
The struggle continues, with new manifest- contexts a measure of success has been
ations of PHC appearing in the form of achieved, for which the reward has also been
'community based health care', 'integrated great. Provision of health care has become a
health and development projects', and joint endeavour between all sections of a
similar approaches emphasising participa- community, with each person making his or
tion, empowerment, and decentralisation. her own contribution to the whole, however
The cyclical nature of the movement small. Recognition of the value of differing
from centre to margin and back again is contributions is now widespread. This process
clear, although there is no straightforward can be viewed as another example of the way
return to a past situation, rather a re- in which various aspects of life continually
emergence of issues and concerns in new move from marginal to central positions.
forms. The re-emergence of an emphasis on Health is often of marginal interest to the
the social nature of health and the majority of community members: a concern
importance of social-support networks in only when it deserts them and they fall sick.
health maintenance which came with PHC Where participation is fostered, the central-
exposed a number of dilemmas. ity of good health to a productive life is
recognised and acted upon. Health becomes
the hub at the centre of the wheel, holding
everything together and allowing move-
Participation
ment in the desired direction.
Within this new context the practitioner An additional benefit of this process is the
appears as a guide, someone with specific way in which it builds trust between health
technical knowledge which is put at the workers and community members. This
service of the needs of the community. The narrows the gap which the training of
distance between practitioners and clients is professional health workers may create
reduced again, as practitioners attempt to between them and the population they
explain their understanding in terms which serve. Practitioners come to recognise the
non-professionals can understand, and to importance of other actors in maintaining
adjust their priorities to those of the com- health and the value of their knowledge. An
munity around them. The pre-eminence of example is the work of SARTHI in Gujarat,
the practitioner is undermined still further, India.3 While attempting to improve health-
as efforts are made to (re)learn more about care provision in the area, project workers
non-allopathic approaches and local under- realised that herbal medicine played a vital
standing of the means to achieve health and
role in local practice. Rather than dismiss-
prevent illness. In this context, practitioners
ing this as old fashioned or irrelevant, the
feel themselves being pushed out to the
project took an active role in discovering
margin as the centrality of their contribution
precisely how these herbal remedies worked
is challenged. Having held such a central
and which conditions they could be used to
position for a considerable period of time,
combat. Unsurprisingly many of the tradi-
many are uneasy at letting go of the reins.
tional remedies proved to be effective against
There is also the challenge of finding a exactly the conditions for which they had
successful mechanism through which com- always been prescribed. The result was an
munity participation can be achieved. A active encouragement of herbal gardens as a
great deal of effort has gone into the study of widely available and affordable health
Over the edge 11

resource. A tradition which had been mar- others less so, and this quite naturally
ginalised by the success of allopathic medic- changes over time. For those attempting to
ine was reclaimed. More importantly it provide services over a sustained period of
remained firmly in the hands of the local time, the prospect of failing to obtain
population, who therefore kept a central role funding is a very real one. The changing
in their own health care. fashions within the health and development
scene do not always work in their favour.
Environment, population, gender awareness,
Funding and bureaucracy urbanisation, responding to HTV, eradica-
tion of polio: these are just a few of the
Fostering the participation of the communi- fashionable issues of recent years. All of them
ty is one challenge. It is quite another to are important and should not be ignored, but
integrate the contributions and programmes many projects are mainly concerned with
of different departments or sectors into the continued provision of basic health care.
efforts to attain overall health goals. One of Valuable time and energy are squandered as
the most serious barriers to this is the nature staff try to fit their proposals to the latest
of departmental budgets and financial struc- fad. Another current favourite is sustain-
tures. Within the bureaucratic structures of ability. Not only is this hard to define; it
governments, it is necessary to maintain may also be unrealistic: can the poorest
strict lines of authority and accountability. countries or regions ever hope to rely only
Money is allocated to achieve specific ends on their own resources? After all, it is not
dictated by the priorities of the department. the case that developed countries do so;
When staff from different departments try to rather they draw on many resources world-
combine their activities or create joint work
wide. Of course, sustainability is not merely
programmes, negotiating the budgetary free-
a financial concept. It has other dimensions
dom to enable this to occur can be difficult.
which are equally important: cultural, envi-
To which department will costs be allocated
ronmental, organisational, political, and social.
for transport, for joint workshops, for pro-
gramme administration? Can all this be
justified? How will differing priorities be
reconciled? Who will be in charge overall The economic margin and equity
(and who will thereby feel pushed to the Perhaps the most pervasive of recent
margins)? In a project to promote good fashions is that in which health is viewed
nutrition through increased agricultural produc- from a predominantly economic perspective,
tion of nutritious food, does the health depart- with cost-effectiveness and value-for-money
ment or the agriculture department take taking priority. The reform movement
charge? These are not idle questions, and while sweeping through public administration
'common sense' may lead us to the conclu- and economic structural adjustment have
sion that the responsibility must be shared, made a significant impact on the thinking of
this is not easy to achieve administratively. health-care policy-makers. The terminology
A further layer of complexity is added by has changed again to costs, inputs, products,
the influence of those agencies which provide efficiency and (less often) investment. A by-
the funds for health care. Application dead- product of this most recent shift has been
lines must be met. Funding is for time- that funding proposals for health-related
limited periods only. Hard evidence of the activities are increasingly being designed
positive outcomes of past funding is with these economic parameters in mind.
required when applying for future funds. The way in which this can potentially
Each agency has its own agenda to promote. distort the project objectives and activities
Certain activities are highly favoured and is open to debate, but there is no doubt that
12 Development foi Health

it is proving very difficult to translate health unlikely that they will accrue to those on
into purely economic terms. The costs of treat- the margins of a society. Of necessity,
ment or illness are slightly easier to estimate, private investors are interested in profit and
but the benefits of health to an individual will concentrate their provision where the
remain hard to quantify in monetary terms. highest profit margin can be gained. Govern-
Practitioners become caught in the tension ments may reduce State provision as private-
between economic calculation of general costs sector efforts increase, especially when
and benefits and provision of humane care to financial constraints operate, using the
individuals in specific need. It is a tension argument that their provision is no longer
which many find impossible to resolve. needed, as the private sector has taken over
Once again it is important to analyse how this responsibility. However, the net result
this new focus changes the centre and the is usually that services for the better-off
margins within the field of health care. multiply, while those for the poor are under-
Assessment of health benefits in economic mined still further.
terms means that the importance of those This pattern is in danger of being repeated
who are economically inactive or invisible on far too large a scale if the supremacy of
is reduced. It also undermines the value of economics continues unchallenged. Health
other contributions to health and well-being and welfare services are cut back with the
which may be of a social or psychological argument that they are not cost-effective.
nature. I am thinking of an older woman I Money is diverted into production of goods
knew in Papua New Guinea. She did not per- for export in order to boost the economic
form any visible economic activity, being growth of the country. That this is a short-
old and weak. On the surface she consumed sighted option may at last be becoming
rather than produced resources; thus there apparent to its promoters, who have
was little incentive to expend still more on previously been dazzled by the sparkle of the
maintaining her health. But what of the nouveaux riches which it has created.
value of her knowledge and wisdom in the Poorly fed, poorly educated, unfit people do
resolution of family or community not make for a prosperous nation. Evidence
conflicts ? What of her value in the education is growing that health is strongly affected by
of the children through myths, storytelling, social divisions. Death rates are higher in
and personal history? What of her know- societies with the greatest gaps between rich
ledge of herbal and household remedies for and poor. The well-known health risks of
common illnesses? How to assess in monet- being poor are greatly increased if we know
ary terms the fact that she can call upon the that our neighbour is rich. Social and
support of other community members in economic inequality do not promote good
times of hardship, just as she has assisted health, though they may create large profits
them in times past? These are vital contrib- for multinational corporations.
utions to the continued health of her com- Compelling evidence of this comes most
munity, but we have a long way to go before clearly from the developed rather than the
we can cost them. Too often the economic developing countries. In the United States
spotlight is turned upon the more straight- and the United Kingdom, the health of the
forward task of assessing the cost of treating poorest has been declining, despite increased
her arthritis or her chronic obstructive lung expenditure on health care and despite
disease: inevitably, she shows up as a economic growth. For the UK, general health
negative item on the balance sheet. was best during times of national crisis: the
Another variant of the economic argument is major world wars of this century. Great
that of the neo-liberalist, urging us towards efforts were made to ensure that everyone
privatisation of service provision. While there had the basic necessities for life (through a
may be some advantages to this, it is highly rationing system), while at the same time
Over the edge 13

the vital importance of everyone's contri- longer realistic. But it is a slogan which
bution to the war effort was strongly empha- neatly summarises much of the foregoing
sised. Divisions were minimised and equitable argument for concentration on the needs of
sharing of the burdens stressed, with very those at the margins. If we have the courage to
real benefits for health. It is sad that it seems learn from what occurs at the margins and apply
possible to achieve this level of cohesion these lessons to the overall system, then
only in the face of an enemy, for in all other although we may never reach every marginal
ways war is undoubtedly the greatest of group I believe we will move a long way
health hazards. Indeed, the difficulties of towards a fully inclusive health-care system.
health-care provision at times of armed
conflict or in its aftermath are one of the
major preoccupations of the present time. Notes
1 The terms maigin and maiginalisation
are used here to indicate those people,
Conclusion ideas, or places which are left out or
It is easy to be cynical about the way in excluded from mainstream policy and
which we provide for the health of those practice. The concept of exclusion has the
living at the margins of our society. We seem same meaning.
to make most demands of those with least 2 PHC as a strategy is based on a few funda-
resources. It is those currently without care mental principles, often referred to as the
who are asked to build their own facilities, pillars of PHC. These are equity, partic-
fund the services they require, and manage ipation, andintersectoral collaboration. The
them in a gender-fair and disability-friendly emphases on prevention and the develop-
manner. The demand for sustainability is ment and use of appropriate technology
made of those living in the most precarious are also central to the approach. Equity
of situations. Meanwhile those with already requires that efforts are directed at those
existing health facilities continue to most in need, in order to reduce any
manage and use them as before. But change existing inequalities in health. It is not
comes in two ways: as a revolution or as a simple equality in which everyone
gradual process. Given the nature of health- receives exactly the same, but a deliber-
care provision which relies on many well- ate redistribution of resources towards
established institutions and a large, often those who have least. Participation is
centrally trained workforce, revolution is valued in all aspects of health and health
unlikely. This leaves us with the option of a care planning, prioritising, implement-
gradual process. It is at the margins of the ing, and evaluating and by all groups of
health system that movement and change people. These two principles in particular
are most possible. It is where the system is have implications for the health of those
not working that we are most likely to try out currently at the margins of any society.
new ideas. It is those who are currently not Intersectoral collaboration requires that
included who can tell us most clearly what the efforts of all government and non-
is needed to reach them. It is in this context government agencies be directed towards
that principles of participation, empowerment, the improvement of health for the popula-
and equity become such potent forces for tion as a whole. Integration of policies and
positive change, through the way in which practical activities to maximise health is
they shift the locus of control and redefine the intended result.
both centre and margin.
3 R.Khannu( 1992): 'Taking Charge: Women's
'Health for all' is by now a well-worn Health as Empowerment The SARTHI
slogan and the target date of the year 2000 no Experience', SAHAJ/SARTHI.
14

Research on women's health:


some methodological issues

T. K. Sundari Ravindran

Introduction done outside the house as well. Further-


more, in most societies women are
This article concerns research on issues frequently victims of violence, both
related to women's health, and particularly domestic and sexual, physical and
applied research falling within the purview psychological.
of health systems, as opposed to clinical or
bio-medical investigation. Research into There is limited knowledge about even
health systems concerns itself with all the some of the most basic health problems of
relevant variables social, economic, women, such as those relating to menstru-
political, and cultural that may influence ation and various infections of the repro-
the health status of a population and their ductive tract; not to mention psychosocial
health-seeking behaviour. It thus addresses and mental-health problems.
broader issues than the planning, organ-
One of the most telling examples of
isation, and delivery of services. It is
failure to apply existing scientific knowl-
important, because, for many crucial
edge to improving women's health status
problems today, valid scientific knowledge
relates to maternal mortality, which in
is available. What seems to be difficult is the
developing countries is 50 times higher than
application of this knowledge for the well-
in industrialised countries a figure which
being of all sections of the population.
indicates the extent of preventable female
There are several reasons why it is mortality in poor societies.
important to focus on women's health.
One of the least-studied areas relates to
Health problems requiring priority care women's participation in solving their own
are different for men and women. health problems, although theoretically this
Factors leading to ill-health vary accord- ought to have been a focal part of studies of
ing to sex. This is explained not only by community involvement.
reproductive morbidity and mortality. The
sexual division of labour means that men We need to know more about various aspects
and women do different tasks, and are of women's health, and in particular we
exposed differentially to various risk factors need answers to the following questions:
and agents causing illness. For example,
What problems do women from different
within the household women usually bear
social groups experience?
greater responsibility than men for cooking,
What are the causal factors ?
waste disposal, and working with water.
What are women's perceptions, and what
There are differences in the nature of work
is their understanding of their problems?
Reseaich on women's health 15

What are the factors influencing their the problem (see Box).1 The 'problems' that a
health-seeking behaviour? research team identifies and the 'solutions'
How can women be enabled or that it proposes depend very much on a
empowered to participate in solving their particular world view: what the researchers
own health problems? see as 'given', and the parameters within
which they function.
Our framework for analysing issues
A framework for analysing concerning women's health is given in
women's health status Figure 1. As can be seen, the components we
have identified are inter-related. Variables
A given methodology is as good or as limited include both those that influence women's
as one's framework of analysis. This is susceptibility to illness, and those that
illustrated by the story of the factory whose influence their response to ill health.
machinery caused serious injuries to its
workers, and the nature of the responses to

There was once a factory which employed backing, with unrestricted access to the
thousands of people. Its production was a factory, a small annual grant, and an
miracle of modern engineering, turning out ambulance to speed serious cases from the
thousands of machines every day. The workshop to hospital ward.
factory had a high accident rate. The But year by year, as production increased,
complicated machinery of the production the accident rate continued to rise. More
line took little account of human error, and more men and women were hurt or
forgetfulness, or ignorance. Day after day maimed. And, in spite of everything the
men and women came out of it with hospital could do, more people died from the
squashed fingers, cuts, bruises. Sometimes a injuries they received.
man would lose an arm or leg. Occasionally Concerned and influential individuals in
someone was electrocuted or crushed to the local community therefore advised the
death. factory management to call in a consultant
Enlightened people began to see that for advice on how to reduce accident rates.
something needed to be done. First on the The consultant pointed out that the
scene were the churches. An enterprising management had thus far neglected
minister organised a small first-aid tent accident prevention, and prevailed upon
outside the factory gate. Soon, with the them to organise a workshop for workers
backing of the Council of Churches, it grew about occupational safety. This had an
into a properly built clinic, able to give first immediate positive impact; but, after about
aid to quite serious cases, and to treat minor a year, accident rates returned to the original
injuries. The Town Council became levels. A second consultant advised that
interested, together with local bodies like workers above the age of 40 should not be
the Chamber of Trade and the Rotary Club. retained on the production line, because
The clinic grew into a small hospital, with their reflexes were slow and they were the
modern equipment, an operating theatre, most accident-prone.
and a full-time staff of doctors and nurses. Nobody in all this time ever questioned
Several lives were saved. Finally the factory why the factory had to have high-
management, seeing the good that was productivity machines at such a cost to
being done, and wishing to prove itself workers' health.1
enlightened, gave the hospital its official
Background Factors
f
3
International
3
N-S power relations transnational pharmaceutical Health Service Factors
influencing trade, aid, and and medical supplies industry, 1
national economic policies population control lobby 7T
National
T^ organisation; financing; coverage and
National distribution; priorities and quality of care

political structure; social co'


Local 00
stratification; resource base;
Local m
resource distibution community structure; in
power distribution; access to services; physical, . ... , ... r

resource base; - r i < pnonties and quality of care


economic and social a.
resource distribution
s
community health culture
I
I
women's health-
- health status of women
a
seeking behaviour

women's status (autonomy; access


i 4
to resources; power and authority) '
illness burden
Research on women's health 17

We start from the premise that disease is a Given the transnationalisation of


natural/biological reality which is both commerce and production, and the inter-
socially produced and socially defined, and dependence of economies across the globe,
influenced by the global and local economic the macro-dimension needs to take into
environment. We also see it as resulting consideration influences of the world
from a process of interaction between these economy on the economy of a nation. A
various factors which are themselves recent work on the influence of world
changing and evolving, both as individual recession on child welfare develops a
entities and as interconnected sub-systems. comprehensive picture of macro-factors and
Our framework consists essentially of four their systemic inter-relationships.2
major components. Our framework also incorporates the
pharmaceutical industry and the
Background factors: the socio-political
population-control establishment, both of
context which influences people's
which have considerable influence on
economic environment and well-being,
national health-service systems. We have
the characteristics of health-service
added a second tier, namely factors influenc-
systems, and women's status in the ing health status at the community level.
society. This is to make allowances for inter-
Health-service factors: how services are community and intra-community differ-
financed (with State funding or as part of entials in the enjoyment of good health and
the market economy), who controls exposure to the risk of disease.
them, their priorities, coverage, and Two major components within micro-
distribution, and the quality of care factors have been identified: (a) the
provided. characteristics of the community to which
women belong; and (b) the health culture of
Women's status: itself the product of a
the community.
number of variables included in
The first set includes the social divisions
background factors, but an important
within the community: caste, race,
determinant with respect to women's
ethnicity, for instance; then the availability
health status.
of material and non-material resources: the
Women's perceptions of health and size of the cake at its disposal; and finally the
illness, and their health-seeking distribution of these resources across the
behaviour: again, determined by the various sub-divisions of society already
interaction between background factors identified. For example, women may be
and community health culture; women's affected because they belong to a very poor
status and health-service factors. sub-section, such as a poor caste or a group of
landless labourers. Alternatively, although
they belong to a wealthy rich sub-group or a
Background factors relatively rich community, they may be
We have considered background factors in affected by discrimination. Or, as is usually
two tiers, consisting of the macro and micro the case, women may suffer as a con-
dimensions respectively. The macro sequence of both poverty and discrimin-
dimension looks into factors which ation. Each must be differentiated, since
influence conditions at a national level, each requires different strategies for action.
while the micro dimension is concerned By a community's health culture, we
with factors influencing health status mean attitudes to health and illness, and to
within a community, and accounting for fertility and its control; beliefs about the
differentials in health status within it and etiology of various health problems;
between one community and another. traditional healing resources commonly
18 Development for Health

used; and the community's attitude to place for women in decision-making bodies
formal health services. Practices and beliefs in the local government or village councils,
concerning menstruation, pregnancy, and through which they can express their needs
childbirth would feature prominently and make demands?
among these.

Women's perceptions of illness, and their


Health-service factors health-seeking behaviour
Health-service factors have also been This is the fourth major influence on
considered at the macro and micro levels. women's health, and is itself mediated by a
National health-service systems are number of the factors and variables already
influenced directly by international factors discussed. Women's status, the health
such as the transnational pharmaceutical culture of the community, and health-
industry and the population-control service factors interact in the process
establishment; and indirectly (through its whereby women decide what to do when
influence on the national economy) by the they get sick.
international economic climate as a whole. A woman's status affects her self-
They invariably reflect the character of the perception about whether she deserves to
national economy whether State-funded take care of herself or not. In some cultures
and subsidised, marketed by the private (like the one I belong to), a woman is not
sector as a service with a price, or consisting expected to complain. A woman would feel
of both private and public sectors, as the case that she has failed as a woman if she could
maybe. not cope: 'Everybody else seems to be doing
At the micro level these factors relate to it. What's wrong with me?'
the resource base and power base of the Again, for certain kinds of illness or for
community in question. An urban com- certain kinds of health event, it is not usual
munity or a wealthy social group thus has for members of the community to seek
better access in general, as well as access to medical help. Since pregnancy is a normal
enhanced quality and more appropriate event, why go for antenatal care? This has
services, than does a poor or a socially more to do with the community's beliefs
marginalised community. about health than with women's status per
se. The numerous beliefs and practices
surrounding menstruation, pregnancy, and
Women's status
childbirth, as well as attitudes to fertility
Women's susceptibility to illness is and its control, which are part of the
necessarily a product of their status within community's health culture specifically
their communities, irrespective of the social affect both women's health and their health-
group to which they belong. Thus, besides seeking behaviour.
income and educational level, indicators of Health-service factors also exert great
women's status would also include social influence: physical as well as social
indicators, for example their level of accessibility, affordability of services in
autonomy and physical mobility, and the terms of monetary and other costs, and
incidence of male violence against them. quality of care.
Mechanisms for women's participation in We have presented a long list of factors
decision-making are also an indicator of that may influence women's health. Some
women's status. Are there groups of women, of these influence women's susceptibility to
formal or informal, in which they can come illness, while the others influence their
together and discuss their health needs, or health-seeking behaviour. It is not that
put pressure on the authorities? Is there a every single one needs to be taken into
Research on women's health 19

account in any given study. Rather, what we may be not to gather more information, but
have presented is a framework for analysis, to gather everyone together to look at what
presenting variables to be taken into they already know. This, then, is a basic
account as impinging on women's health. starting principle.

Observation
Methods of enquiry
Observation can yield worthwhile results
The appropriate research methodology and can be an unobtrusive way of learning. It
depends on the specific purpose of the study can be a very good exercise for an outsider
in question. There may be very simple ways entering a community for the first time, just
of investigating certain questions, while for to watch and observe before shooting off
others we may need sophisticated questions. Effective observation demands
techniques. Facts are only as sacred as the that the outsider has a clear idea of what she
use to which they are put. We need not be or he wants to observe. This is why we
obsessed with being able to produce emphasised the framework in the
quantitative data correct to the last decimal beginning.
point. Observation can, for example, give
Through a combination of qualitative information about the community's
methods and better-known techniques for physical resources; social groupings and
the collection of quantitative data, and the settlement patterns; activities that people
use of existing secondary data, one can engage in ; and differences in living and
gather information related to various working conditions across social groups. It
components of the framework described can reveal where and how women spend
above. However, the methodologies their time, how they are treated, how
discussed in this article are related to only healthy or otherwise they look; whether
one aspect: namely, the collection of there is a visible distinction in the ways that
primary information from the field. These boys and girls are treated... and so on.
are probably not standard data-collection This is, of course, only a first step, a stage
methods, but we present them here in the in which to formulate questions needing
light of having used them in community- further probing, or hypotheses for testing on
based research. All but one relate to the a wider scale.
collection of qualitative information. We
also describe one example of doing a large-
scale health-interview survey with Group interviews
community involvement. Group interviews may take place in
The methodologies described below have informal or formal settings. There are
been useful in gathering information to help several situations when people gather
to assess health needs, to understand factors informally in somebody's courtyard, in
influencing ill health in a given community, somebody's workplace and they can be
and to learn about perceptions and attitudes useful opportunities to find out more about
that affect health. (These methodologies can situations applicable to the community as a
be employed for any exercise in primary data whole. What is the work season? How many
collection, and are not specific to research people get work in general? What are the
on women's health.) wage levels? Are wages different for men and
Community-based research often ends women? For answers to many questions
up investigating what outsiders need to there is no need to go house to house. One
know about what insiders in the can get a general picture from an informal
community already know. In fact, the need group interview. A household survey is
20 Development foi Health

necessary only if more refined information groups within the community, rather than
is needed. treating the community as a homogeneous
More formal group interviews take place entity.
in settings such as workshops, and are The same question may have to be asked
especially useful for research related to of people who you think may have different
women's health. In a workshop setting, perspectives those from different age
groups of women are able to respond to groups, for example, or different power
sensitive questions better than when inter- centres to avoid getting a one-sided and
viewed at home, where they may be reluct- partial picture. For example, we talked to
ant to talk with men or elders around. the public-health nurse and the medical
Formal group interviews are also useful officer in charge of the health centre, to
when women need to be presented with assess their views on what the community
some facts before questions can be posed. needed most, and why services were not
For example, we held a workshop discussion delivered or utilised as planned. And then
on symptoms of gynaecological infections. we talked to some women in the
There were many questions and requests for community to find out what they thought.
clarification from the women. To ask them, This helped us to gain a grasp of varied and
'Have you ever had such symptoms before?' conflicting perceptions, and to identify areas
was then much easier. But in a household for remedial action. Talking to key people is
morbidity survey where you start off asking also useful for gathering specialised
for symptoms, women may often not know information: we spoke with traditional birth
what you are talking about, or may not feel attendants, for example, to find out about
free to share their health problems. birth practices; and with the village
The author has also used formal group headman to learn about relevant State-
interviews to gain a sense of the extent and funded development programmes.
major causes of infant death. When we asked
the group, 'How many of you have lost a
Collecting case studies
baby?' and everyone had, we did not have to
calculate the infant mortality rate in that Case-study collection is useful if, for
community to know that something was example, we are interested in identifying
terribly wrong. For our purposes, this was multiple causes leading to a death,
enough: disability, or serious illness. In the case of
maternal mortality, a woman may have died
'What did they die of?'
of haemorrhage during labour; but there are
'Oh, we don't know.'
many other factors, such as her being poor,
'Did they die immediately afterbirth?'
multiparous, distant from health facilities,
'Yes.'andsoon.
and so on which, in conjunction, were
We discovered that many were neonatal responsible for her death. Case-study
deaths, and that they were not related to collections have helped to identify a number
neonatal tetanus. They seemed more related of non-medical variables that may make the
to the women's health problems during essential difference between life and death.
pregnancy, such as hypertensive disorders,
and to difficulties during labour.
Role-play and drama techniques
Another method which we have found
Talking to key respondents valuable is role-playing by women in the
This is a method often used by social community. This is best organised in a
scientists and anthropologists. It is useful to workshop setting, as in the case of formal
talk to key people in the different social group interviews. This is very useful with
Research on women's health 21

women's groups who are not used to lower-caste settlements of 48 villages, a


standing up and expressing their ideas and total of 3,000 households. A baseline survey
thoughts. But when you ask: 'Can you was done, and the morbidity profile was
portray what happened when such and such updated every month. The researchers then
a woman fell seriously ill in your village?', rechecked a 10 per cent sample of completed
they get together and enact the situation questionnaires in every village, using house
with relative ease. And through their visits. When we found major discrepancies,
portrayal we learn about many of the the entire settlement was resurveyed by a
processes that cause a particular illness, and group made up of researcher/health
the decision-making processes that promoters from other villages, to ensure
determine whether or not medical help is that data were not falsified once again.
sought. The woman falls ill, and then you To eliminate recall errors, we asked
see the role-players asking so-and-so before questions pertaining only to current illness:
they make decisions about what to do,- and what symptoms the respondent was
they perform particular rituals, prepare suffering from on the day of the interview.
certain home remedies, and so on. We would We had a checklist of symptoms related to
never have found out about them by asking common reproductive health problems in
questions, because we would not have been the area and went through it, instead of just
aware that such variables existed. asking the women if they were sick. In order
to reconfirm that symptoms reported did in
fact correspond to the health problems they
Health interview surveys were presumed to denote, we once again
We describe below an example of an attempt relied on a 10 per cent sample of the women
to do a large-scale survey of reproductive who had been studied. A clinical
morbidity in women. It was undertaken by a examination was carried out by a
rural women's organisation, which selected gynaecologist on this sample of women, to
a group of women from the community who give an idea of margins of error and errors
had been trained over the previous couple of specific to certain health problems. We
years as basic health promoters. They were subsequently modified the questionnaire
aware of some of the major health problems and our methods for the next round. We did
of women and children, and could recognise this over one year, and by the end of this
the symptoms. They knew how to treat process we had evolved a fairly trustworthy
them with local cures and simple drugs, and procedure.
to identify when medical help was Such a survey has had several advantages:
necessary. we have gathered sufficient data at a
A workshop was organised for these relatively low cost. The extent of morbidity
women, explaining the need for systematic may be higher than we have identified, but
data collection, and involving them in we definitely know that the prevalence rates
drawing up a questionnaire concerning are at least 33 per cent in our case. A clinical
women's pregnancy histories and examination of a large sample would be
symptoms of health problems. A second ideal, but, since it would also be very
workshop was organised after a trial run of expensive, it would never get done. We also
the questionnaire in one community, in know what the major health problems are,
which doubts and difficulties were clarified. how women interpret their etiology, and so
Questionnaires were checked, and incorrect on.
or incomplete entries were pointed out. More important, however, is the fact that
The women then started the survey. It the survey results are not just sitting in a
was not a sample survey, but a complete computer's memory. Women in the
enumeration of all the households in the community are very much more aware now
22 Development for Health

of their own health problems. Women who women's health. All it requires is the
have been trained as health promoters now willingness and commitment to start with
know more clearly the nature of the local an open mind, and learn from ordinary
problems, and are more effective in treating people. Our task is to challenge the
them. We have tried to summarise the specialists' monopoly over information on
results in pictorial form, and have held what ails women; and to generate
exhibitions in the villages where we information on women's health from the
collected the data. These have stimulated life experiences and perceptions of affected
considerable discussion: 'This many women women information that takes into
complained of this and this. This many consideration women's whole selves and
women went to the health services, and this circumstances.
many didn't go. Why?' We have also had
role-plays enacted by health promoters,
depicting local case-studies, to provoke
Notes
discussion about all the ways in which a
death or disability could have been 1 A modified version of 'The modern
prevented, the identity of the different parable' from It's Not Fair, written and
actors, and the courses of action open to compiled by Anne Wilkinson, Christian
them. Even large-scale surveys can thus be Aid, London, 1985.
actively used as tools for education and 2 Giovanni Andrea Cornia: 'A summary
awareness-raising, and as a way of bringing and interpretation of the evidence',
about local participation in solving people's World Development 12(3), pp. 381-91,
own health problems. 1984.
One further point about the qualitative
methods described above: these methods
can be used even in conventional research The author
where quantitative accuracy is important,
as part of an exploratory phase to get a better T. K. Sundari Ravindran is a founding
sense of the variables involved, or in an member of Rural Women's Social Education
attempt to understand puzzling results. Centre, Tamil Nadu. She has worked as co-
This holds true whether the research editor of the newsletter of the Women's
involves primary data collection or whether Global Network for Reproductive Rights.
it draws on secondary data sources. To give This article is based on a paper delivered by
an example, we discovered on analysing data the author at the National Symposium on
from our health interview survey that newly Women and Health in Developing
married young women received no medical Countries, San Jose de Costa Rica, 4-6 June
help whatsoever when they developed 1991. It was first published in Development
reproductive health problems. On being in Practice in Volume 2, Number 3, in 1992.
asked why, they replied that they were
afraid. The group interview process revealed
that these women were virtually powerless
within their marital homes, not having yet
provided progeny to carry on the family
name. They feared that if they fell ill, they
would be considered a liability and sent back
to their parental homes.
It is clear from the methodologies
described above that it does not require
'specialists' to carry out research on
23

Deterrents to immunisation in Somalia:


a survey of mothers' attitudes

Anne LaFond

Introduction Little was known about women's reasons


for not accepting immunisation. While poor
Throughout the 1980s, international health access to health facilities compounded low
planners argued that increased access to coverage, even where immunisation was
immunisation would rapidly reduce high available, demand remained low. Previous
rates of mortality among children. By 1985, attempts to investigate the reasons for non-
when the worldwide goal of Universal Child completion of immunisation in Somalia
Immunisation by 1990 (UCI 90) was set, revealed a wide range of explanations.
many health-sector development strategies However, few studies were able to determine
focused on increasing immunisation coverage. the relative influence of different factors on
Most Southern governments and inter- people's acceptance of the schemes. (See
national donors declared their commitment Mohammed 1986 and Ministry of Health 1988.)
to achieving UCI 90, and pledged their
To assess the reasons for low demand, the
resources accordingly. By the end of the
national Expanded Programme on
decade, reported figures for immunisation
Immunisation (EPI) and Save the Children
coverage from around the world were
Fund (UK) jointly embarked on a
tallied; and, at the World Summit for
community-based study of immunisation
Children, held in September 1990, Universal
acceptability. The research aimed to assess
Child Immunisation was at last declared.
individual and collective experience with
Unfortunately, global figures tend to the programme, to ascertain the reasons for
mask the less successful experiences. Few poor acceptance, and so determine practical
reports have emerged from those countries ways to improve uptake. However, the
which failed to achieve the UCI 90 goal. Nor research also conveyed to programme
have we learned the reason why these managers an entire history of immunisation
programmes might have failed. Like many at grassroots level. Members of the
countries, Somalia joined the immunisation community were able to explain, in their
"band wagon', launching its national pro- own words, the role which they played in
gramme with great political zeal. In the the drive for Universal Child Immunisation.
latter half of the decade, access to immu-
nisation improved rapidly. Nevertheless,
ten years after the programme began, many
mothers remained sceptical of this particular Background
health intervention. Their reservations Somalia is a country of only 8 million
were expressed as some of the lowest inhabitants. It is estimated that more than
national coverage figures in the world. half the population live a nomadic or semi-
24 Development for Health

nomadic existence. Although the country is had little or no previous knowledge of


linguistically uniform, Somali became a immunisation. Measures used by the
written language only in 1972. Education government to ensure compliance during
levels are poor, and much of the population the campaigns were often extreme. Mothers
remains illiterate. Poor communication refusing immunisation were threatened
networks, remote and migrating communities, with fines or imprisonment; some were
plus a moribund health system all tend to forcibly taken to the immunisation site.
frustrate the consistent delivery of health Health staff, instructed to meet targets, also
care and health information. placed pressure on women and would
Before the overthrow of President Siad actively seek out children whose mothers
Barre in January 1991, the Somali Socialist failed to attend. At this time, many health
Revolutionary Party played a pivotal role in workers were trained to administer vaccines
political and 'official' social life in the country. and gained a basic, but limited, under-
Party workers, representing various sectors standing of immunisation and health-education
youth, labour, health, politics, and agriculture messages. While 'community' mobilisation
were assigned to each administrative division was generally effective, immunisation sites
of every village and town. The government were often crowded and chaotic. Achieving
normally employed them to organise political high coverage often took precedence over
activities and to provide a focal point in the genuine and effective patient care.
community for national development In most cases, the campaigns succeeded in
programmes, including immunisation. raising coverage dramatically. Nevertheless
within a year, rates fell as new cohorts of
eligible children failed to come forward for
The immunisation programme immunisation. In response, the government
initiated a second strategy, opening many
In 1978 the government launched the new sites in most major towns. Situated in
Expanded Programme on Immunisation, Party Orientation Centres, and staffed with
introducing immunisation for women and more newly-trained nurses, these services
children in Banadir Region, which included the aimed to bring immunisation closer to the
capital, Mogadishu. The programme aimed to grassroots and to encourage Party cadres to
immunise 80 per cent of all children aged 11-23 mobilise the mothers. Concurrent efforts to
months against six killer diseases (polio, raise awareness included radio broadcasts,
diphtheria, whooping cough, tetanus, drama productions, 'Mobilisation Days',
tuberculosis, and measles), as well as 75 per and a birth-registration programme.
cent of all women of child-bearing age to From 1985 to 1988, Somalis watched
prevent tetanus in new-borns. Activity immunisation activities achieve national
increased slowly from 1978 to 1985, when
importance. However, despite these efforts
three successive immunisation campaigns
to secure coverage targets, actual demand
were held throughout the country. A number
remained low. In 1989, among children in
of international development agencies actively
Mogadishu, where access was greatest,
supported this initiative, providing substantial
coverage of DPT3 (the third and final dose of
resources to assist the Somali government in
a trivalent vaccine for diphtheria, polio, and
meeting campaign targets.
tetanus) was only 25 per cent; and only 26
By enlisting a network of Party officials per cent of eligible women had received at
and workers, all women of child-bearing age least two doses of tetanus vaccine.
and all under-fives were registered and taken
to specified centres to receive immunisation.
Information was disseminated at community
level through Party cadres, many of whom
Deterrents to immunisation in Somalia 25

Research objectives and approach included in the study to assess the extent of
awareness of immunisation in communities
The objectives of this research were two-fold: which did not have access to health services
to gain understanding of health-seeking and formal immunisation promotion. The
behaviour among Somali mothers, and latter were also selected to provide better
thereby determine the factors influencing understanding of perceptions concerning
the acceptance of immunisation; disease and concepts of prevention. Before
the data were gathered, immunisation
to make recommendations for improving coverage was measured in Yaqshiid district,
acceptance, in order to increase the use Using a standard WHO 30 cluster survey.
made of immunisation services. Current coverage rates in Jamame district
Since the research aimed to discover the were already available, and so no survey was
attitudes and beliefs contributing to low conducted. Coverage of three doses of DPT
demand, researchers took a qualitative approach vaccine in Yaqshiid and Jamame measured
to data-gathering. Previous studies to assess 25 per cent and 34 per cent respectively.
poor acceptance used closed questionnaires
as an adjunct to coverage surveys; and no
Methods
fewer than 15 different reasons for incom-
plete immunisation emerged. Although they Data were derived through three methods:
offered some insight, quantitative methods focus-group discussions with mothers
had failed either to determine the relative assembled by age and parity,-
importance of the different factors or to
informal interviews with individuals
clarify the relationship between them. An
associated directly with the immunisation
open-ended, qualitative approach allowed
programme, and those identified as sources of
for variables to arise from the research and
health advice in the community;
then be explored thoroughly. Potential sensi-
observation of official and traditional
tivity to some research topics also influenced
health practices.
our choice of methods. The immunisation
programme had clear links with political Women selected for focus groups repre-
goals and Party activities. It was assumed, sented all the administrative areas of each
therefore, that some respondents would be community. They were grouped according
loath to speak candidly and critically in to age and parity, reflecting local perceptions of
response to direct questions about a experience and authority in relation to
government programme. child-rearing. It was felt that respect for
older, more experienced women would
hinder discussion if mothers of all ages were
Site selection grouped together. Groups consisted of
One urban community (Yaqshiid district, women aged 16^30 with fewer than four
Mogadishu) and one rural community children; women aged 31-45 with four or
(Jamame district, Lower Juba Region) were more children,- and mothers who had
selected for the study. Criteria for selection completed child-bearing. Discussions took
included the presence of a functioning place in the home of a group member, and
Mother and Child Health (MCH) centre, lasted from one to three hours.
relatively consistent availability of immu- Informal individual interviews were under-
nisation for at least one year, and the taken to complement discussion data and
presence of related outreach activities. provide a wider perspective of local exper-
Data-gathering focused on the catchment ience with immunisation and health care.
areas of both MCH centres. However, in Respondents included officials associated with
Jamame, two additional settlements were the immunisation programme: government
26 Development for Health

and party leaders and health staff; and emotionally. The experience was so striking
community members identified through that respondents in both communities
focus groups as 'health advisers': traditional marked the time in local history as the 'time
and religious healers, knowledgeable older of forced immunisation', tallaalka gasab oh.
women, and midwives. One mother reported, 'I did not decide to
To assess the relationship between mothers take my children. I was forced during the
and health providers and the effectiveness of time they were forcing people. They said,
immunisation messages, researchers "Pay a fine, be arrested or immunise". This
observed activities in MCH centres, is the time I heard about immunisation.'
immunisation sites, and treatment sessions Lack of adequate information, coupled with
run by traditional and religious healers. such campaign enthusiasm, incited fear and
The research team consisted of one expatri- confusion about the purpose of
ate and two Somali researchers. Researchers immunisation. When recalling their
lived in each study site for one month, often experience, respondents often betrayed the
within households or families. All interviews tactics which had been used to avoid
and discussions were carried out in Somali campaign workers, such as moving children
and reviewed, discussed, and written up on to outlying villages or hiding them within
the day of the interview. The following the house. Other mothers reported about the
topics were used to guide the research: campaign, 'There was no decision, just the
Party Committee and the militia. When
awareness and knowledge of immunisation; they come to your door, there is no decision.
attitudes towards characteristics of We are not afraid now, but in the past it was
immunisation: safety, effectiveness, difficult. They knew every mother and they
accessibility, and cost; would say "She is in there, take her out".' Or
perceptions of diseases preventable by again, 'During the campaigns, mothers used
vaccine,-
to be forced to take immunisation, and
perceptions and practices related to many mothers used to escape. This is
prevention;
because at the time immunisation was new
perceptions of methods of promoting and and they did not know whether it would kill
delivering immunisation;
their children or was given for other purposes.
the role of health advice in the community. The militia and the Party members gave
mothers a very hard time. They used to
check house to house for small children and
Results take them to the immunisation place.'

First impressions
Perceptions concerning the safety of
When the Ministry of Health introduced
immunisation
immunisation through national campaigns,
government and health personnel were held Research results indicate that the
responsible for ensuring that all women and experience of the campaign strongly affected
children were registered and immunised. mothers' initial attitudes towards the safety
This first thrust for high coverage set the of immunisation. Methods of delivery and
stage for the future of the programme. promotion often engendered fear and
Experiences reported during the campaigns prompted rumours about the severity of
revealed strong contempt for the way in side-effects. As one group stated, 'After
which immunisation had been introduced immunisation the injection site becomes
to women at the local level. Mothers sick. It does not heal very quickly, so you
described their encounters with the must return to the health service for
authoritarian campaign-workers vividly and assistance. When the mouth of the wound
Deterrents to immunisation in Somalia 11

comes together, then something hardens on diseases. Respondents reported marked


the bone and leaves a scar as if the child had differences in their perceptions of cause,
been slaughtered.' seriousness, and children's susceptibility to
A second theme associated with safety each disease. For each illness, mothers
relates to the tetanus immunisation given to described common practices for prevention
women. At first, most mothers tried to refuse and cure. Their acceptance of the measles
it, because they believed it was contra- vaccine may have been greater because they
ception. Rumours spread that the govern- felt that measles was highly contagious and
ment was using immunisation in order to the most severe of all the EPI diseases.
arrest population growth. Inadequate informa- Moreover, respondents could not identify an
tion, together with the government's drive exact cause for the disease, or a specific
to locate women of child-bearing age, led to means of prevention.
suspicion of the ulterior motives behind the On the other hand, diseases which were
programme. Groups of older women classified as spiritually caused, such as polio
expressed the strongest reservations about and neonatal tetanus, were hardly linked to
tetanus vaccine: 'Why vaccinate girls? It's immunisation. Unlike measles, mothers
not a good thing. It stops child-bearing. It is were clearly able to specify a cause for polio
impossible for a girl to take this. The girls and neonatal tetanus. Reported methods of
who take this vaccination are the ones who treatment and prevention were available
do not want to bear children and want to from healers who specialised in these types
become prostitutes.' of illness. Mothers reported that Western
medical care, such as immunisation, was
ineffective against spiritually related
Effectiveness of immunisation and disease. Hence, traditional practices which
perceptions of disease were seen to address the cause of disease
Lack of awareness about immunisation, and were more highly valued than vaccination.
fears about safety, raised some doubt about Classification of the disease also revealed
its effectiveness. At first, mothers reported that mothers considered tetanus and neonatal
that nothing could prevent the diseases tetanus to be different and distinct from
which are brought by God: 'Ilahy iyo each other. Tetanus was known as tetano,
quranka ayaa ka horteg leh Only God and whose symptoms, cause, and treatment
his Q'uran can protect us'. However, as time resembled the known medical description of
passed, they were able to see for themselves tetanus. Some women had eventually
the benefits of immunisation. Mothers accepted immunisation for prevention of
recalled that their views changed when tetanus in mothers. However, they did not
measles appeared in the community and believe the same vaccine could also prevent
immunised children were not affected. The tetanus in newborns. Neonatal tetanus was
majority of women who displayed a trust in known by a different name: toddoba ma
immunisation had had personal experience gaarto, a phrase which means 'not reaching
of its capacity to prevent disease. As one group seven days'. The name refers to the fact that
stated, 'We have not seen an immunised children with this disease usually die within
child contract measles. Since immunisation a week of birth. Unlike tetano, its cause is
began, these diseases have decreased.' spiritual, and it cannot be treated or
Perceptions concerning the effectiveness prevented with Western medicine.
of immunisation also varied according to A general lack of understanding of the
disease. It was widely thought to be effective way in which the women and mothers
against measles and whooping cough; but perceived disease was reflected in the promo-
was rarely considered to offer effective tional messages used in the programme. For
protection against the other four EPI example, the term used to describe polio was
28 Development foi Health

dabeyl, literally 'the wind', sometimes the MCH, but you cannot receive medicine
referring to a spirit. From the respondents' there. There are also no skilled people to
perspective, dabeyl was a name given to a examine the children. People who have
group of diseases all of which were brought money go to the pharmacies, where they can
by the same spirit, or dabeyl. Messages have the medicine they need.'
claiming that immunisation could prevent Respondents conveyed the view that the
dabeyl suggested to mothers that MCH service rarely provided treatment
immunisation could also prevent epilepsy, when children were ill. 'There is nothing at
madness, and miscarriage, as well as polio. the MCH,' stated one mother. They described
Because such messages were confusing, few services which were generally bereft both of
mothers felt convinced of their veracity. drugs and of sympathetic health staff.
Nurses were perceived as 'young, irrespon-
sible, and careless' and often implicated in the
Health advice misuse of supplies such as medicine and
Reports and observations of traditional food. Consequently, when children fell ill,
healers illustrated their role in influencing mothers preferred to seek care from reliable
health-seeking behaviour. By reinforcing and trusted healers; or to purchase medicine
common perceptions about disease, healers from a pharmacy. One respondent stated:
indirectly affected mothers' attitudes towards 'The government brought the food and the
immunisation. The perceived need for medicine to this MCH, but they gave it to
immunisation against certain diseases (polio, these young girls, who always give more to
neonatal tetanus, and tuberculosis) was someone who is a relative or a friend. Or
often diminished by the availability of care they use it for themselves. People here are
from traditional healers. Indeed, community- poor and have many children, so they need
based health advice proved to be a critical medicine for their sick children. The
component of health-seeking behaviour. immunisation will come next.'
A Somali proverb states that a sick man Mothers also complained that staff failed
has 100 advisers, nin buka boqol u talise. In to explain the purpose and side-effects of
addition to seeking advice from doctors, immunisation. The researchers' observations
pharmacies, and healers, respondents confirmed these experiences. One group of
indicated that they also relied heavily on mothers reported: 'The staff do not like to
relatives and friends, especially at the early talk to the mothers,- they do not give us
stages of illness. As one mother stated, much information about immunisation. In
'Most of a mother's advice is in the neigh- fact, they do not seem to be interested. They
bourhood.' The emerging trust in immun- are doing these things just to send the
isation for measles prevention seemed to be mothers away.'
based on the shared experience of women in
the community.
Discussion
Official health services
Methods of promotion
In group discussions about health advice,
few mothers claimed to visit the official Analysis of women's experience with the
health service, except when encouraged immunisation programme revealed that no
during immunisation activities. Dissatisfaction single factor could account for low demand.
with the level of care available at the MCH Thus, it was necessary to cluster certain
centre was cited by the majority of variables, and analyse the relationship
respondents as a deterrent to regular between them and their relative influence
attendance: 'Immunisation is available at on health-seeking behaviour. The stories
Deterrents to immunisation in Somalia 19

told by the respondents demonstrated that health services in Somalia. Clearly, mothers
many of the obstacles to adequate were keen to find treatment for sick children
acceptance could be traced to programme Yet few felt that the MCH could offer the
design. From the perspective of the bene- quality of care which was required. Inter-
ficiaries, immunisation had been intro- views with health staff confirmed this
duced quickly and insensitively. Gaps in impression of the health service, citing
their basic understanding about the purpose inadequate care as the greatest obstacle to
of immunisation indicated that the health people's acceptance of immunisation. A
messages had often been misunderstood. nurse in one health clinic stated, 'The main
Moreover, the way in which immunisation problem in this community is that people
was promoted failed to inspire trust in its are poor and they need treatment. We would
worth. Ironically, in the aftermath of the not need to use a car with a megaphone on it
first immunisation campaigns, mothers to call them for immunisation if we had
feared for the health of their children, rather medicine. If we could just treat them, they
than feeling assured that they were well would come on their own.'
protected. The poor quality of MCH care also
Throughout the global drive for UCI 90, affected mothers' access to information about
national campaigns were often used to immunisation. Apart from official promo-
introduce immunisation and raise its tion messages, the only source of advice was
profile. However, in Somalia, this type of the health service. Even when mothers did
social and political campaign had been attend, researchers observed that health
employed regularly by the government to education was often poor. Many of the
promote various other national policies. In mothers interviewed after visiting the MCH
the past, campaigns had been staged to centre could not name the vaccines their
ensure Party allegiance, improve literacy in child had received, or say when they were
Somali, promote self-help, and discourage supposed to return for subsequent doses.
tribal loyalties. Respondents likened the When the programme began, health
immunisation campaigns to these regular services throughout Somalia were generally
attempts by the government to promote its in decline. At the time of this research,
own interests. It was, therefore, not immunisation had already become the only
surprising that this method of promotion government health service offered in many
met with suspicion. districts. Few efforts were made to improve
Throughout the duration of the basic health care alongside the introduction
programme, the responsibility for local- of immunisation. Available resources were
level mobilisation remained in the hands of generally targeted on immunisation activities
the Party workers, who often had as limited alone. This approach, which focused so
a knowledge of immunisation as the exclusively on immunisation delivery,
mothers whom they were advising. 'Advice' appears to have contributed to low demand.
about child health from the Party compared
poorly with advice from trusted sources
such as grandmothers, healers, and private Understanding community needs
pharmacies. Why then were so few efforts In many ways, the failure to understand
made to involve community health advisers needs identified at the local level hindered
in spreading the word about immunisation? the success of immunisation activities in
Somalia. People's perceptions of health
needs and official programme objectives did
Context of delivery not often converge. Programme managers
The second most strongly reported deterrent went to great lengths to deliver
to immunisation was the poor state of immunisation. However, they placed less
30 Development for Health

emphasis on demand for it. This was evident encouraged careful attention to the language
in the language used to identify different used in health education to address the most
vaccine-preventable diseases. Health common gaps in knowledge.
messages failed to reflect the widespread Secondly, programme managers
concepts concerning the disease; and suggested that health staff should work
messages consequently missed their targets. more closely with community-based health
Directly and indirectly, respondents advisers to enlist their support for
stated that the immunisation programme immunisation promotion.
seemed to exist for the benefit of those who Thirdly, findings which demonstrated the
ran it. Objectives which were inconsistent importance of curative care for attracting
with the needs and perceptions of mothers mothers to the health service prompted the
in particular hindered the potential Ministry to broaden its approach to
acceptance of immunisation. developing the sector. EPI staff requested
The way in which immunisation was donors and policy makers to provide
introduced and promoted in Somalia resources for strengthening the MCH
mimicked that of many UCI initiatives of services as a whole, rather than
the past decade. It was marked by concentrating all efforts exclusively on the
enthusiasm for rapidly increasing access to a specific intervention.
single intervention. Where the existing
health infrastructure proved too weak to
support the pace of expansion, it was by-
References
passed in order to raise coverage quickly.
Respondents challenged this approach by Ministry of Health, Expanded Progtamme
demonstrating that success was dependent on Immunization, 1988, '30 Cluster Survey
not only on access to immunisation, but of Immunization Coverage in Mogadishu',
also on creating and sustaining a demand for unpublished report.
it. Sustaining that demand would depend on Mohamed, A., 1986, 'Immunization Status
whether programme activities were of Two Year Old Children in Mogadiscio',
addressing the needs of beneficiaries, as well unpublished PhD thesis, Somalia National
as those of programme managers and University.
donors.

The author
Conclusion From 1987 to 1990, Anne LaFond worked
This research revealed an aspect of health with the Expanded Programme on
programmes which is often neglected in Immunisation in Somalia. At the time of
planning. By reviewing individual and writing she was Coordinator of the Research
collective experience from the perspective Programme on Sustainability in the Health
of the users, managers learned for the first Sector at Save the Children (UK). Since 1994
time how local people perceived their work. she has worked for the Aga Khan Foundation
Before the collapse of the former USA, based in Washington.
government, the Ministry of Health and This article was first published in
international agency personnel began to Development in Practice Volume 3,
employ the research results in three ways. Number 1, in 1993.
MCH workers and supervisors adapted
health messages to reflect mothers'
perceptions of immunisation and vaccine-
preventable diseases. Supervisors
31

Participatory appraisal in the UK urban


health Sector: keeping faith with perceived needs

Teresa Cresswell

Participatory Rapid Appraisal will be more firmly rooted in local


conditions, be these social, financial,
Rapid Rural Appraisal (RRA) and its cultural, or political. It can also promote
derivative Participatory Rural Appraisal understanding, dialogue, and working
(PRA) originated in developing countries as a relationships between multi-agency
means of evaluating the needs of poor rural professionals, as well as providing greater
communities. More recently, these methods insight into the needs of the community they
have been adapted for use in deprived urban serve. At best, the process can deepen
areas. There has been much criticism of people's understanding of their problems and
extractive 'community research', whereby opportunities, increase their control over
external researchers go into communities, development choices and plans, and initiate a
learn from local people, leave, analyse the process of participation that can continue as
data, and then draw up development plans plans are put into action. This may be
without further consultation at the through community management of local
community level. Rapid appraisal methods initiatives, or greater awareness of the
allow information about a given set of resources available to them.
problems to be obtained quickly, without a
large investment in professional time and In my work in the UK health sector, I
finance. However, while these include many currently use the term Participatory Rapid
flexible techniques and skills suited to a Appraisal, partly because I work in an urban
community situation (such as allowing for setting; but also because 'participatory'
improvisation), in practice they often fail to implies that local people, as well as key
involve local people in each step of the outsiders, are fully involved in all stages of
process. the process, including deciding what needs to
be asked. 'Rapid' meaning that no more
Participatory appraisal grew out of a than six months elapse from starting the
concern to involve community members in work before concrete actions result
research and decision-making, without because this maximises people's enthusiasm
losing the benefits of speed. By including and motivation, and helps them to see and
local people, or those who use services, at all participate in change, no matter how small,
stages information-gathering, analysis, giving them confidence for more daunting
action plans, and establishing priorities actions. 'Appraisal' is taken to mean the
the appraisal process can become whole process of deciding what needs to be
empowering. A participatory approach also asked, asking, making sense of the
means that the plans are more likely to work information, prioritising and taking
than are those drawn up by outsiders, as they action.1
32 Development for Health

In using PRA to assess health needs in a that provide financial benefits, or education.
deprived urban setting, we had many positive The scope is enormous.
experiences. But in this article I want to It is important to go at a pace that
discuss some of the problems encountered, so individuals are ready for. My experience is
that others can learn from our insights. that, while it takes a long time to engage
people enough for them even to consider
participating, you then have to move quickly
Some basic principles to capitalise on their new enthusiasm and
motivation. Small initiatives in response to
PRA is essentially a collection of research and demand give confidence, and allow people to
communication techniques used to elicit see something working, before moving on to
qualitative data. Quantitative data can be more difficult tasks.
gathered using PRA, but more traditional It is vital to stay with the whole process
research methods for statistical analysis can until the community or individuals are ready
also provide these. and willing to take charge; researchers should
Firstly, I strongly believe that a commit- then act as 'consultants' as and when
ment to the communities and the people required.
who live there is a pie-requisite. People in the Finally, researchers should avoid trying to
UK, particularly in disadvantaged mining influence the process to meet their own
communities, are fed up with being used as needs and be sure to have adequate
'research data' or for 'statistical purposes' to resources to get started.
demonstrate the numbers of unemployed,
the levels of stress, the impact on health and
so on, without this making one iota of
Learning by doing
difference to them as individuals, or to their
communities. In my experience, in times of There is often a lot of uncertainty about
recession, hardship, and bleak prospects, employing less traditional research methods,
most people want and actually need partly because of scepticism towards 'outside
something in return. It is easy for outsiders professionals'. But in the UK there is a
not worn down by poverty and its effects to be growing need to find out from people
enthusiastic and committed to their task. themselves what it is that will improve their
Through working with people who are health. It is recognised that traditional
disadvantaged, either through poverty or ill- methods of health care are not always
health, I have seen that ,unless they stand to appropriate to meet the changing needs of our
gain something, they cannot even begin to communities. Statistical information will
consider the wider issues outside their only tell us the numbers of people who are
immediate family and neighbourhood. This attending clinics for immunisations and so
lies behind the failure of so many on, or the numbers of people who are
'community initiatives'.2 suffering from a specific illness. It will not tell
So the first pre-requisite is a commitment us why people do not make use of services
to helping people to gain whatever 'positives' available to them.
are appropriate to them as individuals In 1988 I was hired to work part-time to
wanting to improve their health. identify the health needs and related social
The second is good all-round commun- needs of an economically deprived com-
ication skills: you need to be able to munity suffering high unemployment. The
communicate with people, not patronise brief was to identify needs and develop
them. Lobbying and advocacy also involve services or initiatives in response to these,
communicating with councils, doctors, without the requirement of significant extra
health or social workers, or with agencies financial resources.
Participatory appraisal in the UK urban health sector 33

Staveley, a small town in north-east evolved, with poor social networks and
Derbyshire, had suffered heavy job losses family-support systems.
when the local coal mine and chemical works I set out to find what the families who lived
closed down. The population was around in Mastin Moor perceived their main health
16,790. The initial task was far too great, so I and social problems to be. I did this quite sub-
broke the locality down into small distinct jectively. I knocked on the doors of house-
'communities' or housing clusters, with holds which-looked as though they were not
which local people identified. coping: for example, homes which seemed
To select a 'community' to focus on first, I neglected, whose gardens were litter-strewn,
approached the relevant professionals who or full of junk. Or I stopped mothers in the
lived and worked in the area, and asked them street, at the school gates, or in a local play-
which community was giving them the most group. I asked health visitors to identify
concern. Health visitors, district nurses, families that might be willing to talk to me.
midwives, and family doctors were asked to I used informal open-ended questions
identify their worries, based upon health about what they thought their health and
status, and attendances for recognised health social problems were, and recorded inform-
checks, in particular health and development ation in a small notebook. The main themes
checks for babies, immunisation sessions, were of social isolation, limited access to
and ante-natal clinics. Schools were asked health and social care, the lack of pre-school
about attendance, and pupils' ability to take provision, and the lack of anywhere to meet.
up educational opportunities. Social workers This reinforced the views of the local
were asked about the families who were professionals, and confirmed my own
experiencing child-care difficulties, and observations.
about incidences of child abuse. The police I did no further investigation and decided
were asked about the communities they were to develop a social project in response to these
most concerned about, as were youth and specific needs. With the support of
community workers. Clergy were asked nine mothers, we met several times in their
about communities and individuals who homes to discuss the way forward. They
appeared to experience the greatest social identified an under-used community centre
difficulties. Local councillors were also asked to set up a 'drop-in' service, with creche
to give their opinions and support. facilities. It was to be a place for mothers and
It became clear that Mastin Moor, a small others to meet and socialise, and develop
housing estate on the outskirts of Staveley, other initiatives they thought would be
was thought to have the highest level of useful. The project was well supported by the
social and health problems. This mainly local health visitor, who was regularly
council-owned estate of 500 houses, with a available.
population of about 1,800, was originally The most important aspect was that the
built to accommodate local miners and their mothers had full control over the project.
families. With the pit closures, it was left They ran it, and we were there only by
with high unemployment, isolated and with- invitation. It went on to include the provision
out easy access to health and social services, of sewing machines and classes in sewing,
or to shops selling fresh fruit and vegetables. joinery, and photography; health-education
Many families moved out, since it was not sessions on relationships, human sexuality,
an ideal place to Live, with no employment child care, cot deaths; and much more. They
opportunities nearby. As a result the council ran jumble sales to raise money and organised
had empty properties, which were used by outings for the children. The project grew
people who were homeless or in need. This from nine mothers in October to over
quickly destroyed any 'community' spirit 100 members (not including the children!)
and comradeship, and a divided community the following June. Over 20 women went
34 Development for Health

with their children to a residential college, for allocated to Coal Board employees in order of
training in assertiveness and other skills. status: at that time people viewed it with
Several went on to further education, and pride. With the recession and pit closures of
others to paid jobs. the 1970s and 1980s, the community suffered
This experience taught me the importance severe unemployment, which accounted for
of handing over to local people, not making over 15 per cent of the population by late
decisions on their behalf but developing a 1991. In the 1970s, a new housing policy
process whereby they can acquire the meant that accommodation on the estate was
confidence to take more control over then- based not on employment but on need.
lives. Through this, they become more People rehoused there did not necessarily
articulate in identifying their real needs: and, share the traditional working-class values of
more importantly, they take better advantage others already on the estate. As outsiders
of what resources are available.3 moved in, there was no work or social focus
to offset the destruction of the old
community; about 60 per cent of households
relied on Housing Benefit (a form of public
Naming the process assistance). The community is sharply
I had no name for this methodology, but the divided: those who are in paid employment,
process was simple: ask the people who live the original mining community, and the
there, and the people who provide the elderly form one group,- while unemployed
services, and look for yourself. Match the people and single-parent families form the
three with any existing statistical data, and other. The latter were identified as
you can begin to identify the main needs. experiencing more problems with children
Then allow community members to decide and with vandalism.
how they want to tackle the problem. This The initial aim was to identify the health
should ensure community ownership and and social needs of the various population
participation, and start the process of groups in the community, such as elderly or
empowering people. middle-aged people, families, children, and so
I later attended a lecture given by on. We based our approach on the experience
Professor Hugh Annette of the Liverpool of Hugh Annette and Susan Rifkin in Sefton
School of Tropical Medicine (LSTM), a (Liverpool), and their book WHO Guidelines
pioneer in the use of PRA in Health Care in for Rapid Appraisal to Assess Community
Urban Settings in the UK. We met and talked Needs: A Focus on Health Improvements for
about incorporating some of these Low Income Areas (1980).
techniques in my work. North Derbyshire It was felt that the only way in which
Health Authority is quite innovative, and statutory agencies can be truly participative
was already using less traditional techniques is for the 'management' (that is people who
to reach local people, and develop services have direct access to financial and other
more appropriate to what they perceived resources) to leave their offices, get to know
their needs to be. So the Authority was very the communities, and ask the questions.
receptive to my using PRA techniques.
Three managers would do each interview
two asking questions, and one taking notes
to reduce the element of bias. The idea was
The Danesmoor Project that these would belong to a multi-sectoral
team, but this proved impossible to achieve,
The formal use of PRA in north Derbyshire not because they were unwilling; but because
was set up in Danesmoor, a community of it proved unrealistic to get three managers
about 3,000, not unlike Mastin Moor. When from different agencies to meet up, be trained
the estate was built in the 1950s, houses were in PRA techniques and interviewing skills,
Participatory appraisal in the UK urban health sector 35

spend time on interviewing and then more Community members were approached, and
time on the analysis although we did give after several weeks five mothers said they
it a try. More significantly, we decided that would like to train. Creche provision was
the participation of statutory authorities made. But they did not follow through, for
(Health Service, Education, Social Services) various reasons: a job offer, moving home,
should be their commitment to allocate feeling too scared, no time.
resources to outcomes of the research. All I could do was proceed on my own.
A Steering Group was set up to oversee the Several weeks into asking questions, one 'key
project, with a health visitor, a family doctor, community member' said she would like to
a social worker, a school nurse, and others help. She was a local councillor, a single
from the social services, community educa- parent already working for a social-work
tion, and local health authority. They were certificate, and had lived in the community
all new to PRA, and not enough time was all her life. She was a real asset.
given to helping them to understand the pro-
5 Over 54 interviews not including
cess, its strengths and limitations. This led to
sessions with 200 children in eight school
confusion about what the exercise could
groups were completed over a three-
achieve. There were difficulties in deciding
month period, though only about 34 working
'what questions to ask', and how to respond to
days were actually spent on this part of the
the findings. Our main mistake was trying to
exercise. I was involved in all of these, except
move too quickly, without a working
where I had worked with people previously,
understanding of what we could achieve.
since this might have hindered free
communication. The interviews were with
The step-by-step process4 three main groups:
1 A Steering Group was established to a. Key Professionals
oversee the project and design questions, Health Visitors
based upon the data we already had and District Nurses
professional concerns for the area. School Nurses
Family Doctors
2 Questions focused on four broad themes:
Head Teachers
People's perceptions of the area and the Nursery Teacher
community: what is it like living there? Librarian
The evident health and social problems. Midwife
Existing care-service provision, and Community Mental Health Workers
community needs. Social Workers
Within reason, what would benefit Domiciliary Services Organiser
individuals, families, and the community Police Inspector
as a whole? Housing Manager
3 Health visitors, school nurses, and district Clergy
nurses were all 'advised' that this was going Pharmacist
to 'happen' to them, which unfortunately Dentist
created a feeling of antagonism towards the Youth Leader
PRA process and its outcomes. And they b. Key Community Members
were all so busy that there was little Councillors
opportunity to participate. However, health Shopkeeper
visitors contacted certain families to Publican
facilitate our talking to people in the area. Welfare Rights Worker
4 It was impossible to get other professionals Playgroup Leader
to help in the interviewing process. Five Key Community Members
36 Development for Health

c. Community Members disciplinary team within the community;


23, including 10 lone parents a nursery and pre-school activities;
200+ children the inclusion of community activities
within the school;
6 Interviews took place in people's own
facilities and resources for young people,-
homes or place of work. They were confid-
improved parks and play areas;
ential, and took about one hour each. Inter-
an investigation into the dangers of toxic
viewees were advised that interviews would
waste from a local factory, and other
be documented, and that I would read back
environmental issues;
my notes to them, or they could read them for
a community newsletter and better
themselves. This gave people confidence that
communication systems.
what I had written was what they had said. It
also enabled clarification, and served as a 10 Feedback was a problem. I was under
memory-jogger to elicit further information. pressure to complete the work and present it
The one-hour limit was to respect their to the Health Authority. An interim report
busy lives, and the fact that after this time was produced for discussion, and an open
people tend to become repetitive, and get meeting was held, to which all participants
tired. In fact, only about 30 minutes was were individually invited. It was attended by
given to pure 'fact finding'. Fifteen minutes about 30 people. Members of the Health
were for selling the project, and 15 more for Authority were unhappy with the outcomes,
clarification and closing the interview. and with people's perception of their services;
All the interviews were recorded in one and unfortunately they took the report to be
shorthand notebook. Analysis and further final, rather than the basis for what could
writing took about 25 working days after the have been a productive dialogue. Commun-
interviews had been completed. ity members were very happy with the report:
one said, 'It's the best thing that has come out
7 I recorded one focus-group discussion on ofDanesmoor'.
video, and we photographed relevant features
It also caused a lot of bad feeling between
in the area: a litter-strewn river, and an
health professionals and myself. They felt
inadequate bridge. The quality and type of
that the sample gave a biased perception of
houses were photographed, as were play areas
the services, and was too small to be of
and so on. This made it easier to relay
consequence. They tried to dismiss commun-
information back to the authorities.
ity members' 'needs' as 'wants'. Some workers
8 It soon emerged that the main difficulties felt that it was not appropriate for them to
on this estate concerned single parents, and attend an open meeting; and to my know-
their relations with established members of ledge they never responded to the report.
the community. For this reason the project Comments such as 'We knew all that anyway'
which was supposed to be generic changed were typical. In reality, I suspect they were
to focus only on the needs of such parents. hurt by the negative feedback on the services,
This is the beauty of PRA. It is flexible, and and tried to dismiss the criticism as unrepres-
this change did not compromise our project. entative and personal. Whatever the reasons,
It was acknowledged that the needs of other it affected their ability to consider the chang-
community members would have to be ing needs of the community they served.
investigated to get the full picture.
HThere were many organisational prob-
9 A number of priority needs were identified lems. At a management level, there was not
and mutually agreed by the participants: enough commitment to considering how to
a central facility for community and social change service-delivery to meet current
activities; 'consumer' needs. The project was
relocation of professionals as a multi- inadequately resourced, and there was no one
Participatory appraisal in the UK urban health sector 37

in post to follow up the study (though this has Following this, we set up a project in which
since been resolved, with a community local people were paid to train as inter-
health post designated for the area). viewers, so we could get a 'complete com-
Many professionals, especially in the munity perspective'. This is not easy, since
health service, did not understand the PRA most people feel they have nothing to
process, or have confidence in qualitative contribute, and that they are not 'good
research, and so they tried to discredit it by enough' to be interviewers. However, exper-
focusing on quantitative aspects of the study. ience shows that, once they are trained and
Nevertheless, the doctors were well aware of fully involved in the process, people enjoy it
the harmful effects that social and economic and gain confidence. But because of some
disadvantage can have on health. reticence to accept the Danesmoor findings,
Community members complained about we involved more interviewers, who went
the lack of resources and help in meeting the back for two or three follow-up sessions to
priorities identified. check the validity of the findings. We work
On the positive side, some agencies as well on the premise that in the first interview
as the local council did take up the findings of people tell us what they think we want to
the study; a Danesmoor Action Group know. In the second, they tell us what they
developed; and single mothers were enabled know. In the third, they tell it how it really is.
to get together and form new friendships and An example of this approach is the Safe
support networks.5 Communities Project, in which we aimed to
identify the safety needs of a community that
had experienced a relatively high rate of
Some lessons for the future childhood accidents. While it was not always
easy to use the information gathered from
What we learned from this experience is that local people, the practical outcomes were
before undertaking any such exercise it is successful. We set up first aid and home-
vital to take the time to involve all the rele- safety courses, while the police installed
vant professionals and community members, safety cameras, and local schools became
ensuring that they understand the process, involved in a major safety campaign. We later
and what the outcomes may be. We also real- received funding for a low-cost home-safety
ised that, although PRA is quicker and more equipment scheme, with a local store acting
flexible than traditional methods, it needs to as the retail outlet. This avoided the stigma
be complemented by other research data. attached to 'hand-outs', and allowed people
The overall aim was to provide a means for freedom of choice in deciding what, if any,
professionals and local people to unite in equipment to instal.
order to improve the health of the commun- Once health and other authorities accept
ity. Incorporating PRA should enable service- that qualitative research using PRA can help
providers to understand the 'whys' and them to understand people's needs, it is
possible 'hows' when it comes to making imperative to back this up quickly with
changes to existing provision. It can help pro- action, so that changes can be evaluated.
fessionals to be more responsive to people's What is important is not the size of the
own perceptions of need, and creates new project, but the fact that it works, that it
potential for dialogue between the providers involves people at all decision-making levels,
and users of services. By breaking down and that the outcomes, no matter how small,
barriers, it can promote an atmosphere of can be seen.
partnership which is important not only in The results of the action may take time.
the initial stages of any project, but also for For example, the Poolsbrook and Duckman-
evaluation. But attracting people to partic- ton Health Projects began in 1993, in com-
ipate is the hardest part of the exercise. munities disadvantaged through loss of jobs,
38 Development for Health

river pollution, isolation, and high public- professionals must be involved throughout
transport costs. The concept was to provide the process. Data and findings should be
10,000 per year to each community for three recorded accurately, checked, and fed back
years for the purposes of improving their quickly. This maintains information-
health and social needs. The process was exchange, and enables us to capitalise on
protracted. People were at first uncertain people's enthusiasm and motivation. Other-
about taking responsibility for the money: wise the key feature of 'speed' is lost.
'What if we get it wrong?' It was sometimes Attempting something small, that is
hard to convince them that there were no achievable, gives vital confidence to the
rights or wrongs, only outcomes. Once they flinders, the professionals, and, most
took on the responsibility, they came up with importantly, to the community as a whole.
more ideas than they had money to spend, No external professionals could adequate-
including many that would not have been ly express the feelings behind statements
thought of by health workers or other made in the interviews, such as 'We need
professionals. For example, when the coal help, not blame', or 'People think I don't care,
mines were working, the community were rather than can't manage'. This is evident
screened for chest complaints. Now they are when outsiders interpret 'needs' as 'wants',
shut, people continue to live in an area that is thus diminishing people's own perceptions of
mined by open-cast methods, so they still the situation in which they live. People
experience dust-related problems; but there coping with poverty and hardship place a
is no mass screening. Could the money be different emphasis on many aspects of life,
spent on that? The dialogue has been rich. some of which may seem insignificant to an
The communities are now making very good outsider, but they enhance or degrade the
decisions. Being given responsibility has daily life of the individuals concerned. Those
enabled them to consider their options who play a professional role cannot reliably
seriously, putting them on a stronger footing interpret the 'needs' of community members,
in dialogue with the service-providers. It has nor make effective decisions for those com-
been a learning experience for everyone, and munities, without first understanding how
one of the most important outcomes has been these needs are seen by people themselves.
the development of mutual respect. If professionals are to be more responsive
I work on the counselling concept that to individuals and communities, we have a
'enough is enough'. In other words, if it is duty to respect their perceptions and
good enough for the clients, leave it. If they perceived needs and to use the information
can work with what they have, know, and constructively to enter into a dialogue which
understand, don't complicate it. People will will enable us to develop truly responsive
come back when they are ready. The strength community-based initiatives.
of PRA is that it accepts diversity, by
'triangulating' or using several sources and
means of gathering information, and perspec- Notes
tives. 'Truth' is approached through building 1 The term 'rapid' is questioned by many,
up diverse data direct observation, semi- who feel the emphasis should be less on
structured interviews, putting together speed and more on acquiring 'usable
diagrams, using photographs and video to quality information'. A preferable title
contribute to a progressively more accurate might be Participatory Appraisal, with the
analysis of the situation. understanding that it is rapid.
Dialogue is essential, to avoid the 2 I do not believe that people in Western
problems that arise when local people's urban settings have a concept of
concerns are perceived as criticism of local 'community', nor that they are necessarily
professionals. Community members and altruistic. When people struggle with
Participatory appraisal in the UK urban health sector 39

adversity, they have little left to give. The toxic waste; and making a formal applica-
old saying 'When poverty comes through tion from the Danesmoor Community
the door, love flies out of the window' sums Group for a community house.
this up well. People have problems in
meeting their own needs, and often feel as
though they are getting nothing back for
The author
themselves. This is why the concept of
community does not function as well as we Teresa Cresswell holds a joint post of
might want. If we embark on any kind of Locality Health Promotion Coordinator with
PRA, there should be built into it a method the North Derbyshire Health Authority and
of 'giving back' to individuals, to improve Primary Care Development Co-ordinator
social and health opportunities, and build with the Community Health Care Service
self-esteem. Only when people feel they (North Derbyshire) Trust. She is a registered
are getting something in return will they nurse and health visitor, and currently
feel like contributing to 'community' Manager, in coordination with the Chester-
actions and even then we may in fact be field Employment Services Agency, of the
talking about neighbourliness or shared Unemployment and Health Project.
interests (such as being parents of children This article was first published in
at the same school) rather than a broader Development in Practice, Volume 6,
commitment to 'community'. Number 1, in 1996.
3 A more detailed account of this project can
be found in my report for the North
Derbyshire Health Authority, 'PRA An
Investigation Into the Health and Social
Needs of People Living in Danesmoor In
Particular the Needs of Single Parents and
Children'(1992).
4 This and a similar project was filmed by
WHO in a video entitled 'The District',
which compared 'bottom-up' approaches
to health care in three countries:
Zimbabwe, Indonesia, and the UK.
5 A sample of the practical steps that have
been taken following the PRA exercise and
report includes starting up a mother and
toddler group,- getting the police to provide
two special constables to patrol the area
(which succeeded in halving petty crimes
and teenage vandalism); getting the
council to agree a special fund for any
community group willing to assist in an
environmental clean-up; looking into the
possibility of formal and informal play
areas; introducing a dog warden service to
address the problem of fouling in public
areas,- removing public obstructions from
pavements, to allow access for wheelchairs
and pushchairs and reduce safety hazards,-
investigating concerns about pollution and
40

Stressed, depressed, or bewitched?


A perspective on mental health, culture, and religion

Vikram Patel, Jane Mutambirwa, and Sekai Nhiwatiwa

Introduction very different societies of Western Europe


and North America (referred to as 'Euro-
Mental illness, in its broadest sense, is one American' in this article), whence the bulk
of the commonest afflictions affecting the of development funds originate. Instead, we
human race. The World Bank report on will attempt to show that community
health and development (1993), though health problems and service delivery must
criticised for the unreliability of some of its involve understanding and assisting those
data, identified 'neuropsychiatric' disease as with mental-health problems from within
the second-most important non-commun- the context of their own society. Although
icable cause of disability in the developing we focus on SSA nations, because of our
world (Blue and Harpham, 1994). Of these personal experiences in Zimbabwe, we
diseases, depression was the single most believe that much of what applies to these
important diagnosis. The report emphasises settings may apply to other less developed
an aspect of health which is intimately countries also.
related to a community's overall health
The article begins with a description of
status and development, and which has been
what is meant by the term 'mental illness'
ignored by development agencies and
and moves on to examining some of the
Health Ministries faced with the pressing
ways in which culture and religion
claims of communicable diseases and the
influence mental illness. We end with our
health problems of mothers and children.
views on how culturally appropriate
However, it is impossible to separate the
mental-health services should be developed.
mental and spiritual components of health
from physical illness, in particular when
dealing with chronic illness and maternal
and child health problems. It is likely, and What is mental illness?
desirable, that future health-related
development work will, and should, include It is of great importance for all health and
mental health among its priorities. With development workers to recognise that the.
this future in mind, we focus in this article term 'mental illness' does not refer to a
on the close relationship between mental homogeneous group of problems, but rather
health, culture, and religion. We hope to to a number of different types of disorder. It
inform those who are involved in mental- is even more important to recognise that,
health services in sub-Saharan Africa (SSA) although every society has people it views as
of the problems caused by simply trans- mentally ill, the use and construction of this
lating concepts and ideas developed in the concept may vary considerably from one
society to another. The group of disorders
Stressed, depressed, or betwitchedl 41

most often associated with mental illness mental illnesses, not least because of the
are the psychotic and affective disorders, Cartesian dichotomy which for over a
such as schizophrenia and mania. There is century has influenced thinking in the field
little doubt that such severe disturbances, of bio-medicine (by which we mean modern
which affect virtually all aspects of a Western medicine, based on the principles
person's mental and behavioural life, are of the natural sciences). This dichotomy
recognised in most cultures and societies in holds that the body and mind are distinct.
SSA (Patel, 1995). It is this group of disorders Although contemporary health practition-
which occupies so much of the time and ers are encouraged to consider the integrated
financial resources of mental-health role of both mind and body in their patients,
services in Euro-American societies and for if patients present with symptoms for which
which psychiatric drug treatments have there are no corresponding physical signs or
proven to be of considerable value. Despite findings, many practitioners will conclude
the powerful evidence of a genetic role in the that they must be mentally ill. As
aetiology of these disorders, the environ- psychiatry and its allied professions have
ment plays at least as great a role in determ- evolved in the North, such vague and poorly
ining the course and outcome. For instance, defined illness entities have become reified
schizophrenia seems to have a better out- into precise categories; the latest WHO
come in developing countries, despite the classification of mental disorders includes
fact that mental-health services are under- no fewer than 60 categories of illnesses
developed in these very settings. In other previously classified as neuroses, including
words, even though Europe and North phobias, anxiety disorders, and mild
America have extensive mental-health and depressions (WHO, 1992). Neurotic
social-welfare services, people with schizo- disorders are the commonest group of
phrenia fare worse in those countries than mental illnesses and are particularly
sufferers in India or Nigeria. Recognising common in primary care and community
that the course of even the most 'medical' of settings; recent studies in Zimbabwe
all mental illnesses is so profoundly suggest that up to a quarter of clinic
influenced by socio-environmental factors attenders may be distressed. In this article,
gives cause for concern to those who wish to we refer to this group of problems as psycho-
recreate a mental-health service modelled social distress because, as we will discuss
on the Euro-American system of health care, later, referring to them as a mental illness is
without evaluating the possible therapeutic fraught with conceptual problems.
ingredients already existing in some SSA
societies, such as the role of the extended There are several other areas of health
family and traditional treatments. problems in which psychiatry has claimed
an expertise, including childhood problems
Another group of disorders classified by such as conduct disorders, abuse, and
Euro-American psychiatry as mental mental handicap; the abuse of substances
illnesses has been historically called the such as alcohol and drugs; mental disorders
neuroses. These disorders maybe thought of associated with HIV infection,- and the
as exaggerated forms of normal reactions to psychological consequences of violence and
stressful events. Thus, anxiety, depression, trauma. While each type of disorder has its
and physical symptoms in the absence of a own unique characteristics, there are some
physical disease are experienced by many common features such as, for example, the
people in response to stressful events, and in influence of adverse socio-economic events
neuroses these experiences become more on these disorders as well. Thus, many of the
intense and often out of proportion to the general points made in this article would
stressors (Gelder et ah, 1983). Over time, apply to these disorders.
such problems have been conceptualised as
42 Development for Health

Religion, culture, and mental societies, but may mean something quite
illness different; for example, rather than being
viewed as a mental problem, it may reflect
These are complex issues which have been the patients' assessment of their socio-
of great interest to anthropologists, and economic and spiritual state.
more recently to mental health profess-
The difficulties in translating even basic
ionals. Within the scope of this article, we
concepts are illustrated by our experience
will focus on some areas to illustrate how
with an apparently simple question, asking
religious and cultural factors are intimately
patients about any previous history of emo-
related to mental illness in the community.
tional or mental illness. In Euro-American
While we recognise that culture and religion
societies, a substantial proportion of people
are complex and dynamic concepts, in
would understand this to include depression,
focusing on the relationship between
anxiety, or indeed many stressful situations
mental illness and culture and religion in
which resulted in their consulting a health
this article, we have taken a unitary, and
worker. It was virtually impossible to trans-
perhaps simplistic, view of these concepts.
late the question adequately into the Shona
language, without giving the impression
Concepts of mental illness that we were dealing either with 'madness'
(and thus alienating most of our patients) or
The medical speciality of psychiatry has its 'stress' (which many of them experience,
roots in Euro-American professional views owing to adverse socio-economic circum-
of mental illness. This is vividly demon- stances). This is a seemingly trivial example,
strated by WHO classifications of mental but it represents the very heart of the issue of
illness, which, though purporting to be
mental health and development. It is for this
'international', dismiss illness types des-
reason that we refer to neurotic mental
cribed in non-Euro-American cultures as
disorders as psycho-social distress states.
either 'culture-bound' or not even worthy of
In many societies, then, such distress
recognition (Patel and Winston, 1994). The
commonest neurotic disorders, in this states are not viewed from a medical
classification, are depression and anxiety. standpoint. If depression is not considered to
Patients in Euro-American societies increas- be a 'mental illness' (as psychiatry under-
ingly understand that concepts such as stands it), then should we attempt to change
'depression' relate to a state of psycho- the entire meaning of the term, so that it
logical distress. Over time, the health worker conforms to the dominant Euro-American
and patient acquire similar explanatory paradigm? Is there any evidence to suggest
models for the distress state. In many SSA that the 'medicalising' of such distress
societies such disorders are recognised as states, as opposed to the application of socio-
being distress states, but are not understood spiritual models, has produced any
in the same way: the concepts used to significant benefit to patients? While recog-
understand and explain their causes and nising that the fundamental experience of a
nature may differ widely. Thus, similar distress state is universal to all humans, we
states of distress evoke recognition from the believe that the contextual meaning of the
local community and health workers in distress is of singular importance. Such
Harare, but the causes are perceived as meanings should be respected and under-
closely linked to the interaction of social, stood, rather than referring to an imposed
economic, and spiritual problems (see foreign model to explain the problem.
below) afflicting the person (Patel et ah, One area which illustrates the complex
1995). The same concept, semantically interaction of personal misfortune, religious
translated, can be elicited in this and other beliefs, and cultural values is that of witch-
craft. Although witchcraft is outlawed in
Stressed, depressed, or betwitchedl 43

many African societies, beliefs in its power However, in the context of Buddhist cultures
remain alive, and sociologists have argued in Sri Lanka, Obeysekere argues that a
that such belief systems help to make negative answer to this question indicates
misfortune understandable (Chavunduka, not 'a depressive, but a good Buddhist'.
1994). From a Euro-American perspective, Thus, 'hopelessness lies in the nature of the
what does feeling bewitched mean? Can it world, and salvation lies in understanding
be reduced to a psychiatric 'symptom'? Or is and overcoming that hopelessness' (Obey-
this belief a way that some communities sekere, 1985). In this context, then, eliciting
have developed to explain why life has its the idiom of hopelessness would yield
difficult moments? Should the diverse and positive responses, but the contextual
unproven psycho-theories of the North, like meaning of the term is very different. In the
psycho-analysis and general systems theory, Shona language, the term for sadness is
be imposed on other cultures? kusuwa. This term not only implies
personal sorrow and grief, but is also used in
the context of describing an emotional state
Idioms of psycho-social distress which is a prerequisite for sympathy,
Beyond these broad concepts is the issue of empathy, and reaching out for help and is, in
idioms used by people in psycho-social this context, a positive emotion.
distress. A fundamental difference between Another example is the spiritual experi-
mental health and physical health is that, in ential events which occur in many religious
assessing mental health, one relies almost movements in African societies. Thus,
entirely on what a person tells the health hearing or feeling the Holy Spirit, feeling
worker. Language becomes the very essence that the ancestral spirits wish to come out or
of expressing distress, and emotional terms express themselves, or sensations of being
such as 'sadness' and 'fear' cannot be possessed by such spirits are not only
translated without examining the overall commonplace among members of some
context of the use of these terms in a religious groups, but indeed are highly
community (Lutz, 1985). valued personal experiences. If mental-
Idioms like 'feeling sad' have gradually health workers are unaware of the contexts
become professionalised by medical per- of these experiences, they may see them as
sonnel into 'symptoms' and then taken one symptoms of a mental illness.
step further into becoming 'criteria' for
specific types of 'mental illness'. This
process is intimately related to the historical
evolution of conceptualising human distress in
Priests, prophets, and
Euro-American culture. However, much
psychiatrists: what do people do
mental-health research and development in
when in distress?
SSA societies has assumed that the idioms In Zimbabwe, religion is inseparable from
of mental-health problems as defined in health, and this relationship applies to both
Euro-American settings can be applied traditional and Christian religions. First, let
simply by a semantic translation of terms. us consider the relationship of traditional
The following examples show how this medicine and religion. Traditional medical
approach may confound the process of practices of the indigenous people have a
interpreting the manifestations of psycho- religious foundation, based on local views
social distress in different cultures. on the creation of humankind, the life cycle,
The idiom of 'hopelessness' is central to concepts of growth and development, and
the Euro-American model of depression, and the purpose of life in the Creator's scheme of
questions such as 'Do you have hope for the things. In Zimbabwe, and many other sub-
future?' are often asked of the patient. Saharan African societies, there are
44 Development for Health

extensive beliefs in a spiritual world 'scientific' and traditional medicine, relying


inhabited by ancestral, alien, clan, and evil instead on the Prophets and faith-healers
spirits. These beliefs play an important role within their church for healing.
in guiding people when they are distressed The dichotomy between 'scientific' and
(Mutambirwa, 1989). Traditional healers are traditional medicine is rooted in the fre-
recognised by many as being able to heal the quently held belief that bio-medicine is
sick, by virtue of their intimate knowledge superior when applied to physical and bodily
of herbal medicines and their special ability aspects of health, by virtue of prescriptions
to be possessed by or communicate with of scientifically prepared medicines, oper-
spirits. When seen in a Euro-American ative procedures, investigations, and hospit-
context, traditional healers assume many alisations. On the other hand, traditional
roles, including those of a priest, a legal healing and faith-healing are often viewed as
adviser, a social worker, and a counsellor providing a holistic health-care service.
(Staugard, 1985). Thus, health problems associated with the
Christianity is the most popular denomi- physical body as well as with the mind-soul
nation of organised religion in Zimbabwe. and the social and spiritual environments
The origins of Christianity are historically are healed (Chavunduka, 1978). While
linked with the colonisation of this region. psycho-social distress states have become
Christian missionaries believed that tradi- medical-ised and in Euro-American society
tional religion was pagan. Since beliefs in are increasingly treated by a growing legion
spiritual causation were inextricably inter- of mental-health workers ranging from
woven with misfortune and illness, tradi- counsellors to psychiatrists, in Zimbabwe
tional medicine was also unacceptable. The and many other SSA societies these distress
repression of traditional beliefs by mission- states are often inextricably linked to
aries, in collusion with the colonial admini- spiritual and social factors. In keeping with
stration, led to large numbers of people these beliefs, a significant number of people
taking up the Christian faith and being suffering from psycho-social problems
taught to shun traditional healers. Many consult religious leaders such as pastors,
Zimbabweans today claim Christianity as priests, prophets, and traditional healers in
their main religion, but in practice many search of emotional relief.
such Christians continue to believe in the
power of witchcraft and of their ancestral
spirits and see little conflict between these
Helping people with psycho-social
beliefs and official Church doctrine problems
(Bourdillon, 1987). Furthermore, Christian- In Euro-American society, theories to
ity is practised in this region in diverse ways, explain personal distress have moved from
with a wide range of 'independent', Pente- the spiritual realms to the psycho-analytical
costal, and Evangelical churches, some of realms and, more recently, to a host of new
which syncretise Christianity and indigen- theories including cognitive, behavioural,
ous religious beliefs. It is not uncommon to systemic, social, and interpersonal theories.
see charismatic pastors, in particular from Each of these conceptualises distress states
the Apostolic churches, who assume the or illness categories according to certain
role of a spiritual healer and heal the sick theoretical postulates, which are then
with the power of the Holy Spirit, make extended to actual therapeutic interventions to
prophecies for the future, and encourage the alleviate the distress. Success with such a
congregation to join in spiritual experiences, therapy is then used as a validator of the
including trance states and speaking in theory itself. One example of such a therapy
incomprehensible 'tongues'. Interestingly, which has gained prominence in Euro-
some Apostolic churches shun both American society is cognitive therapy, in
Stressed, depressed, 01 betwitchedl 45

particular for depressive states. Like many form of traditional treatment? Or is the
contemporary approaches, it emphasises the increasing use of 'therapy' as a judicial
personal responsibility of the patient in recommendation for people who break
attaining the cure. Cognitive theory postu- social codes and laws, such as sexual
lates that the fundamental problem in offenders in the North, in fact an analogy to
conditions which manifest as depression or Shona sanctions?
anxiety is maladaptive thinking. The treat- Many imported models employ techniques
ment is aimed at assisting the individual to which are not culturally acceptable to
recognise the maladaptive nature of his or patients in other societies. For example,
her thinking and then attempt to change many patients expect to be told what to do
this. This theory is firmly rooted in the to alleviate their distress, and the role of the
introspective individualism of the North, silent facilitator, typical of some Euro-
and is in sharp contrast to the 'external' American psycho-therapies, may be
models of distress in communities in SSA. inappropriate in many counselling situations.
To date, we are not aware of any studies This is clearly evoked by the 'guru-chela'
attempting to evaluate the effectiveness of relationship between counsellor and patient
these psycho-therapeutic models in SSA. described in India, in which the psycho-
Furthermore, it is well recognised that one
therapeutic relationship mimics that between
of the most powerful predictors of response
a teacher and student, with emphasis on the
to psycho-therapy is the 'congruence' or
counsellor providing direct advice and
sharing of models of illness by therapist and
guidance to the patient. Indeed, dependence
patient, so that those patients who are
on others in the Indian context is a desirable
'psychologically minded' are the ones most
state of existence and does not have the
likely to respond. We would argue that the
negative connotation which it carries in
same principle may be applied to other
Euro-American society (Saxena, 1994).
cultures, so that therapies whose theoretical
models are congruent for patients and
healers are likely to be successful: spiritual
rituals, for example, are likely to be effective Developing appropriate mental-
for spiritual problems. This, of course, health services
would be at odds with trying to change the
We have demonstrated some of the ways in
patient's view of the problem so as to suit an
which culture and religion are profoundly
alternative, often imported model used by
intertwined with mental health and illness.
the therapist.
In this section, we consider how mental-
One example from Shona culture is the health services may be developed in a
behavioural state of kutanda botso. This manner which is culturally appropriate.
state, which is characterised by a person Most development activity in mental
wandering away from home dressed in rags health imitates Euro-American models of
and begging, may be seen to be similar to the illness and health-care delivery. These
psychiatric category of 'brief reactive ignore the contextual meaning of such
psychosis'. However, it is often a tradition- culturally defined terms and categories of
ally sanctioned ritual to cleanse a person illness and the role played by 'non-
who has committed a grievous social crime professionals' in the alleviation of distress.
such as striking his or her parents. By adopt- When seeking to fund or provide new
ing such a vagrant role, perpetrators will services, agencies concentrate their efforts
absolve their misdeeds and correct the on creating new positions of counsellors and
spiritual imbalance caused by their actions. on training them in methods of counselling
Is family therapy, as prescribed by Euro- developed in altogether different settings.
American practitioners, superior to this All too often, this is done without
46 Development for Health

examining what was already happening in health workers in the medical services were
the particular setting, as if people with appalled by this apparent neglect by the
psycho-social problems were previously parents, but they were oblivious to the
unattended to. Development activity power of religion and culture in influencing
catering to vulnerable groups of individuals, treatment choices in Zimbabwe.
such as refugees or HTV-infected people, The close bonds between religion,
identifies counselling as one of the ways of culture, and mental health in many
alleviating their distress. However, it societies in SSA have important lessons for
remains unclear whether this has involved development and health workers involved
working with the pre-existing network of in mental-health care. In attempting to
'informal' counsellors. In Zimbabwe, it provide mental-health services, including
appears that some of the counselling counselling, to any population, develop-
approaches mimic imported methods, such ment funds should be targeted at what the
as systematic therapy, and employ culture finds acceptable and workable,
counsellors with a professional background rather than trying to recreate a Northern
modelled on Euro-American health-care model. The first step must be to get a close
approaches. Only rarely does one encounter understanding of the religious beliefs and
any published, structured evaluation of the social structure of the society and to
impact of these counselling techniques on investigate the pre-existing network of
the life of the patient. It seems that this issue informal counsellors. Research into the
is often taken for granted, under the nature and cause of psycho-social distress is
assumption that if it works in Euro- an essential prerequisite to delivering
American society, then it must do so in services. Collaboration with local health
other societies. workers from professional backgrounds
In this context, we wish to point out that akin to those of their Euro-American
'cultural spectacles' affect not only Euro- colleagues must be extended to local priests,
American workers but also growing traditional healers, village chiefs, and
numbers of people in SSA, who, by virtue of community workers selected by the
education and/or religion modelled on Euro- community. For any mental-health
American societies, are equally in conflict initiative to be successful, it must reach out
with the majority of their kin. For example, to the ordinary person and must be sensitive
professional 'scientific' medicine has taken to his or her world-view. And most
firm root throughout the world, and its important, one must refrain from imposing
practitioners in Zimbabwe, though them- an invalid foreign category, since this will
selves coming from a society with rich and only alienate the people it is meant to help.
extensive beliefs in ancestral spirits, will We need to understand what the communi-
often suppress these traditional beliefs ty means by mental health and illness, its
because of the dismissive attitude taken by priorities in mental-health care, what it
what is historically a Euro-American discip- believes are the ways in which such
line of health care. Such health workers, problems can be tackled, and so on. Idioms
though integrated within the bio-medical of distress need to be generated from the
approach to health delivery, are not necess- language of the people, rather than relying
arily representative spokespeople for the on simple translations from a foreign
community at large. A very recent example language. There is little doubt that many
of this is an epidemic of measles which led themes of distress are universal to humanity,
to the deaths of several children from a but it is equally important to recognise
particular Apostolic church whose congreg- those characteristics of distress unique to a
ation shun bio-medical treatment and particular community. Any intervention
immunisation. Most policy makers and must be evaluated from the context of the
Stressed, depressed, or betwitchedl 47

individual and the health-care worker. New a situation, our most urgent message is that
measures, such as the Shona version of the mental health needs to be firmly on the
WHO Quality of Life Instrument (Kuyken et agenda of development activity. It is
al., 1994) and the Shona Symptom important to recognise that mental illness
Questionnaire (Patel et al., 1994) may be as defined in Euro-American society does
used to evaluate counselling and other inter- not translate with the same contextual
ventions for psycho-social distress. meaning in many African countries. Thus,
The influence of religion and culture on what is often regarded as a mental illness is
mental health is being recognised in Euro- to be found in the broader realms of socio-
American society, where increasing spiritual problems, which we prefer to call
numbers of professionals are writing about psycho-social distress. Such distress is
the need to recognise the spiritual intimately related to a community's overall
dimension of a person's health (Cox, 1994; sense of well-being and development, to its
Sims, 1994). We would go further in stating economic strength, to its network of social
that this dimension is important not just for and spiritual relationships, and to the
mental health, but for physical illness as indigenous health carers and religious
well, in particular for severe illnesses such leaders in that community. In delivering
as AIDS, for which medical treatments mental-health services, development activ-
remain unaffordable, unavailable, or ity should recognise these important inter-
actions between mental health, culture, and
ineffective. These spiritual dimensions are
religion.
rarely accessible to bio-medically trained
health workers, who should admit this and
allow open access to such patients by relig-
ious and traditional healers. This already Acknowledgements
hapens in facilities for terminally ill and
psychiatric patients in Europe and North We thank Mark and Cathy Winston, Paul
America (Stephens, 1994). Ironically, in Linde, and Laurie Schultz for their
societies where spirituality and health are comments on this paper. Vikram Patel is
inextricably linked, health workers seem to supported by the Beit Medical Fellowships,
resist this need of their patients. GTZ (Harare) and IDRC (Canada) in
conducting a research programme on
primary mental-health care in Harare.
Conclusions
Mental illness is a significant cause of References
disability in the development world and has
been largely ignored in health-related Blue, I. and T. Harpham (1994) 'The World
development activity. In many SSA societ- Bank "World Bank Development Report
ies, the impact of economic structural' 1993": Investing in Health', British Journal
adjustment in impoverishing the people, the of Psychiatry, 165:9-12.
breakdown of traditional community and Bourdillon, M. (1987) The Shona Peoples,
family relationships caused by urban Gweru: Mambo Press.
migration, and the devastating effect of Chavunduka, G.L. (1978) Traditional
AIDS are likely to cause an even greater Healers and the Shona Patient, Gwelo:
impact on the psycho-social health of Mambo Press.
individuals. There is abundant evidence Chavunduka, G.L. (1994) Traditional
that most of these problems are not Medicine in Modern Zimbabwe, Harare:
adequately dealt with in government- University of Zimbabwe Press.
funded primary health-care settings. In such Cox, J. (1994) 'Psychiatry and religion: a
48 Development for Health

general psychiatrist's perspective', Botswana: Traditional Healers, Gabarone:


Psychiatric Bulletin 18:673-6. Ipelegeng.
Gelder, M., D. Gath, and Mayou, R. (1983) Stephens, J. (1994) 'A personal view of the
Oxford Textbook of Psychiatry, Oxford: role of the chaplain at the Reaside Clinic',
Oxford University Press. Psychiatric Bulletin 18:677-9.
Kuyken, W., J. Orley, P. Hudelson, and N. World Health Organisation (1992) The ICD-
Sartorius (1994) 'Quality of life assessment 10 Classification of Mental and
across cultures', International Journal of Behavioural Disorders, Geneva: WHO.
Mental Health 23:5-28.
Lutz, C. (1985) 'Depression and the
translation of emotional worlds' in Culture
The authors
and Depression (ed. by A. Kleinman and B.
Good), Berkeley: University of California Dr Vikram Patel, formerly Beit Research
Press. Fellow at the Institute of Psychiatry (UK),
Mutambira, J. (1989) 'Health problems in runs a community psycho-social health
rural communities, Zimbabwe', Social research unit in Goa, India. Dr Jane
Science and Medicine 29:927-32. Mutambirwa is a Senior Lecturer in Medical
Obeysekere, G. (1985) 'Depression, Anthropology and Behavioural Sciences in
Buddhism, and the work of culture in Sri the University of Zimbabwe Medical
Lanka', in Culture and Depression (ed. by School. She is a co-ordinator for the Health
Kleinman and Good), Berkeley: University Systems Research Programme in the Uni-
of California Press. versity of Zimbabwe. Dr Sekai Nhiwatiwa is
Patel, V. (1995) 'Explanatory models of a psychiatrist working for the Ministry of
mental illness in sub-Saharan Africa', Social Health in Zimbabwe. She has worked in
Science and Medicine 40:1291-8. mental health in Nigeria, the USA, and UK.
Patel, V., F. Gwanzuia, E. Simunyu, A. This article was originally published in
Mann, and I. Mukandatsama (1994) 'The Development in Practice, Volume 6,
Shona Symptom Questionnaire: the Number3,inl996.
development of an indigenous measure of
non-psychotic mental disorder in primary
care in Harare', in Proceedings of the
Annual Medical Research Day, ICHE,
Harare: University of Zimbabwe Press.
Patel, V. and M. Winston (1994) 'The
"universality" of mental disorder revisited:
assumptions, artefacts and new directions',
British Journal of Psychiatry 165:437-40.
Patel, V., T. Musara, P. Maiamba, and T.
Butau (1995) 'Concepts of mental illness and
medical pluralism in Harare', Psychological
Medicine (in press).
Saxena, S. (1994) 'Quality of life assessment
in cancer patients in India: cross-cultural
issues', in Quality of Life Assessment:
International Perspectives (eds. Orley and
Kuyken), Berlin: Springer.
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mind?', British J. of Psychiatry, 165:441-6.
Staugard, F. (1985) Traditional M~edicine in
49

Training indigenous workers


in mental-health care

fane Shackman and fill Reynolds

Introduction As trainers with experience in the field of


refugee rehabilitation, we were approached
Hans Buwalda's article, 'Children of war in by a British worker who had just been
the Philippines' [Development in Practice, appointed as a Training Officer for a non-
Volume 4, Number 1, February 1994), government organisation (NGO) in Croatia.
describes some of the emotional problems of
Her main role would be to train Serbo-
children in the Philippines, traumatised by
Croatian speaking workers in counselling
political violence, and relates her intro-
skills and mental-health care for their work
duction of Creative Process Therapy at the
with displaced people from Bosnia. A
Children's Rehabilitation Center in Davao
psychiatric social worker herself, she had
City. It raises interesting issues concerning
years of experience in the mental-health
the modification and application of a
field, in various different settings but she
Western therapeutic model to a South-East
had no experience as a trainer, nor in work
Asian country experiencing long-term
with refugees. She was clearly anxious about
conflict.
her role, and phoned us for advice two weeks
We would like to explore this further in before going to Croatia.
relation to the kinds of training programme She asked, among other things: How do I
that are currently being developed in former plan and run appropriate training courses?
Yugoslavia and other areas of war or civil
What will the participants want to know?
war. The aim is to train workers from ethnic
How do I find an effective way to share my
minorities in mental-health care and
own skills? Attempting to address some of
counselling skills, to enable them to work
these issues, we offer this article to everyone
with refugees and displaced people who
working in similar areas of conflict.
have been subjected to war and extreme
brutality, including detention, rape, and
torture. All will have been affected by these
experiences, and some may have been First thoughts
seriously traumatised. The training If you feel anxious about the limitations of
programmes and subsequent mental-health your own skills and experiences in an
work often take place in over-crowded and unfamiliar context, remember that this may
under-resourced refugee camps, or in be how the participants on your training
situations where fighting still rages, and courses will be feeling. If you feel daunted by
basic needs for safety, food, and shelter can the task ahead, this may well reflect some of
barely be met, let alone social, emotional the fears of those whom you are setting out
and mental-health needs. to train in mental-health work.
50 Development for Health

We suggest that addressing participants' understand and come to terms with their
own concerns and anxieties is a good way to own mixed feelings about the work they are
start such a training course. It will enable going to undertake. They are likely to have
you to identify more clearly their training feelings of impotence and inadequacy, even
requirements, and increase their confidence sometimes of despair, as well as hopes,
in expressing and asserting their needs. commitment, energy, and creative ideas.
It will be important to combine your own Acknowledging such emotions does not
therapeutic approaches with the cultural form a separate 'topic' in training, but runs
frameworks and ways of working familiar to throughout the entire course. You need to
participants, so you need to become as build in opportunities for participants to
familiar as possible (as quickly as possible!) reflect on and talk about their own feelings
with the local cultures, values, and about the work, and indeed about the
situation, and take account of these in your training exercises you have asked them to
training programmes and models of work. do, and the feelings these may stir up.
The participants on your training courses The aim is to help workers to deal with
will be a rich source of information and their feelings of being overwhelmed or dis-
knowledge, and they should be able to work tressed. Remember that they are intimately
with you to adapt ideas into culturally involved with the conflict in ways that you
appropriate ways of working. are not. They are likely to share many of the
losses and traumas of those they will be
working with. That gives them both a
The selection of trainees unique strength, in understanding and
empathising, and a vulnerability, in that the
The trainees' own experiences, knowledge, work may leave their own sorrows exposed.
and status within their communities will In addition, clients can be very
affect how they are seen and are able to demanding, angry with workers who are
function. Selection needs to take account of unable to provide what they want, and jealous
their standing and status within their of workers' paid employment. The workers
communities, if they are to be trusted and will have responsibilities that are new to
well received. Primary heath-care workers them, such as assessing clients for propensity
or community health promoters, for to suicide and this can be a heavy burden.
example, will usually be known and trusted, Mental-health work is often painful and
and may be possible candidates for training draining. The training should help workers
courses. You may have little control over to recognise their own emotional needs, and
selection of trainees when you first arrive, support them in their right to ask for help
but ideally you should introduce a sensitive themselves. One Bosnian worker in the UK
selection procedure. Clearly the existing works all hours of the day and night, so that
knowledge and skill-level of trainees will
(she says) she can keep her feelings of
guide the design and process of your course.
distress at bay. She has no access to
continuous support and supervision. This is
one way of dealing with painful feelings that
Emotional impact of the work threaten to overwhelm us, but workers
should be given opportunities to seek and
In training people to work with refugees and receive support from others.
displaced people, you need to address the There are many ways in which you can
emotional impact of the work on the pay attention to the trainees' emotional
trainees. No matter what ideas, training
responses, and you will have to make judge-
modules, exercises, and frameworks you
ments about how far deliberately to encourage
bring, it is important to help participants
self-disclosure in the groups with whom you
Training indigenous workers in mental-health care 51

work. If people have been working hard to together in smaller groups on a regular basis,
keep their feelings of distress at bay, they if they work in nearby geographical areas; or
will not welcome being stripped of their they may ask the organisations employing
defences. Exercises and discussions which them to establish a support or supervision
give participants the opportunity to 'put structure. You will probably need to back up
themselves in the position of the client' can such requests by holding your own
be a gentle way to give recognition to discussions with employing organisations.
participants' own needs for support. Burn-out is a real factor in this type of work:
An exercise on 'Asking for help' (Open after a while workers themselves can
University 1993) draws attention to the become depressed, bored, or discouraged
anxieties and loss of control that people (van der Veer 1992), and support networks
often feel in seeking help. for them need to be established early on.
Participants work in threes and each person
is asked to think of a relationship with
which there were difficulties.Whether or not Create a safe atmosphere
they sought help in improving the If you can create an atmosphere of trust and
relationship at the time, what difficulties openness, where trainees feel comfortable
could there have been for them in asking enough to share their anxieties, fears,
someone outside the relationship for help} vulnerabilities, hopes, and ideas, and to
When all three have discussed what might acknowledge the emotional impact of the
have made it hard to ask for help, they are work on themselves, they will be prepared
then asked to consider what additional to take risks in learning and trying out new
factors might make it difficult for refugees, techniques in working with clients. If you
or those who have been traumatised, to ask create a safe atmosphere, trainees will be
for help. able to make better use of any structured
You can vary this exercise by making activities and exercises which you introduce,
'difficulties in working relationships' into and to practise, challenge, and adapt new skills.
the focus. It is in either case likely to give How can such an atmosphere be created?
rise to some acknowledgement of trainees' Think about how you will introduce the
own needs, and their feelings of ambiva- training course, and the way in which you
lence in seeking help. intend to work. Proper introductions are
important, and the chance to 'warm up'
Often clients will not talk immediately
through non-threatening activities. We
about emotional problems, but may discuss
often use an exercise which combines
more practical concerns. Trainees can be helped
elements of introductions and warm up.
to attend sensitively to these demands, to
build up trust first, before trying to open up Ask each participant to tell the group about
more emotional topics for discussion. his or her name, and what it means. Each
person speaks in turn for a few minutes
only. Participants will decide for
On-going support for workers themselves how much they want to share at
this stage. If you start, you can set the tone
In times of conflict, normal support net-
for others. The exercise gives opportunities
works are disrupted or broken completely,
for people to talk about their ethnicity,
and new ones may need to be built. Training
family history, religion. It is surprising how
courses give an opportunity to start this
much a name can mean to its owner and
process. Allow time for trainees to discuss
how quickly a few words on this can give
what kind of support they need, and how it
others in the group a glimpse, revealing
could be provided. They may be able to meet
more of the whole person.
52 Development for Health

You can use warming-up exercises for a few Participation is one of the keys to a
minutes at the beginning of each new session: successful training course. We believe that
something light-hearted before serious busi- people 'learn by doing', and by reflecting on
ness begins, and a chance for individuals to their own work. It is possible to achieve a
feel connected again with the group. Talking high level of participation by starting where
about something which they have enjoyed they and their communities are.
recently, or a memory of the last session, are The theoretical underpinning for this
other ways of giving each person a moment approach comes from the ideas of Paulo
to say something at the start of a new session. Freire on popular education. Freire's literacy
Giving each person a turn is less embarrass- programmes for slum dwellers in Brazil
ing for them than if you put pressure on an involved people in group efforts to identify
individual to speak in general discussion. their own problems, to analyse critically the
Exercises can help people to think about cultural and socio-economic roots of the
issues from a different angle, and should problems, and to develop strategies to effect
promote discussion. A good approach is to positive changes in their lives and in their
move from individual work through paired communities. In effect, people teach
conversation to small-group discussion. If themselves in dialogue with each other.
people have had a chance to note down their Paulo Freire's advice on this process is
own thoughts first, they are more likely to relevant:
feel confident enough to talk to one another,
Every human being is capable of looking
and then to enter into group discussion.
critically at his world in a dialogic
Encourage everyone to participate, using
encounter with others ...In this process, the
their own experiences and ideas, and value
old paternalistic teacher/student
all their contributions. Acknowledge and
relationship is overcome. A peasant can
deal with the emotions that are evoked.
facilitate this process for his neighbour
Give plenty of opportunity for participants
more effectively than a 'teacher' brought in
to use their own case-studies and examples
from the outside. Each man wins back his
in their paired and group discussions. own right to say his own word, to name the
world. (Freire 1972)

Training methods While trainees on your courses may hope


You may find that the way of training which that you are coming as an 'expert', to impart
we are advocating is very different from solutions to the problems with which they
what trainees expect. Perhaps they hope you are grappling, you are more likely to be
will present lectures, or teach more formally; struck by the fact that you are working in a
whereas we are suggesting training that is country, culture, and situation where your
experiential and participatory, with you in knowledge is limited. You may wonder
the role of facilitator rather than teacher. We whether your experience and skills are
believe this can be negotiated with the relevant. It is important to clarify your role
group, by explaining your training methods early on: you do have expertise and tech-
and the reasons why you use them. But you niques to share, but as a trainer you are there
may need to make some concession to your to help trainees to recognise and draw on
trainees' preferences. This could be by their own resources and skills. You are there
giving some short prepared inputs, perhaps to help the group to tap their own wealth of
summarising learning and discussion from experiences and creative ideas. We find that
earlier sessions. It is hard for people to adapt case-studies and role-play help this process.
to unfamiliar learning styles, and you will
In small groups of four or five, trainees can
need to take this into account.
think of a real or hypothetical client they
Training indigenous workers in mental-health care 53

are worried about, or you can present a How did your parents or care-givers make
prepared case-study. After reading the you aware of important values!
outline of the case, and particularly the Circle the values that you consider to be
presenting problem, ask trainees to discuss peculiar to your cultural, ethnic, or racial
in their groups (1) what do you feel!, (2) group.
what do you think!, (3) what are your first Place a tick next to the values that you
steps going to be!, (4) how are you going to still adhere to and a cross next to those
approach the client, what are you going to that you no longer adhere to.
say! After discussion, trainees can role-play
Participants then work in groups of three to
the start of the interview with the client.
discuss their responses (Christensen 1992).
They may be surprised at values which are
Role-play should be seen not as a test, but
held in common, despite cultural
as an opportunity for trainees to practise
differences, or at different interpretations of
different ways of intervening, and to receive
what values mean in terms of behaviour.
feedback about their impact and ideas about
They can recognise that most values are
other approaches. Those in the role-play and
passed on by example and non-verbal
the observers can swap places to try out
means. Participants will usually identify
different strategies. Linked with discussion,
the dangers of imposing their own value
planning, and review, and done in a
system. If the group you are working with
supportive environment, role-play can be
share a common cultural background, this
one of the most effective ways of learning.
exercise brings out differences in emphasis,
interpretation, and upbringing. This is
helpful in cautioning trainees against
Cultural considerations assuming that they and their clients share
There may be considerable cultural differ- common values and aspirations.
ences between yourself as trainer and your
trainees, just as there may well be differ- Again, opportunities for participants to
ences within your group of trainees, and think about their individual responses and
between the trainees and the clients with to work first in small groups are important
whom they will be working. You cannot in giving everyone a chance to be heard, and
assume that trainees understand everything allowing differences to emerge.
of their clients' backgrounds and values, just There is still a risk of inadvertently
because they are members of the same wider imposing your own cultural bias and value
community. An examination of cultural system in your powerful position as a
expectations, values, strengths, and differ- trainer. It is not always easy to recognise
ences on training courses is important, in your own cultural 'spectacles' (Finlay and
order to sensitise participants to their own Reynolds 1987). For example, your own
cultural norms and biases in relation to their professional social-work training, if rooted
clients, and to encourage them to build on in Western, Anglo-Saxon, and Christian
inherent cultural and community strengths in values, has probably tended to focus on
coping with losses, crises, and traumas. personal, rather than collective, achieve-
ment, fulfilment and satisfaction, and to
Here is an exercise which can open up
have valued independent thought and
discussion on different cultural values.
action. The individual perspective is not
Participants first note their responses always central. Be prepared to have your
individually to the following instructions: own assumptions challenged.
List six values passed on to you by An awareness of gender-linked differ-
parents or care-givers. ences is vital. How men and women are seen
in their culture, and the investments they
54 Development for Health

have in it, are not necessarily the same. and displaced people feel guilty about the
Their responses to pain and losses, how they deaths of loved ones, and have been unable
process these, and their willingness to to grieve for them.
express emotions may differ. Therefore you Crisis intervention is another theoretical
will have to give thought to how you might framework which can be useful, so trainees
handle training groups composed of both can look at the more normal stages of trans-
men and women, and how you will deal ition in a person's life (such as adolescence,
with issues that may generate different marriage, unemployment, old age), and how
reactions and responses according to gender. they are differently affected by unexpected
Sexual crimes, such as rape during civil crises or changes. Times of crisis are
conflict, would be a case in point. It may be difficult and painful, but sometimes can
helpful to give participants opportunities to present opportunities for positive, as well as
work in same-sex groups on some topics, so negative, changes.
that people have the chance to work out Training in assessment skills is a useful
their ideas before sharing them with the tool, in helping to identify what a client may
mixed group. need, and who needs additional help.
Trainees can be helped to distinguish
between 'normal' distress and more serious
Course content mental-health problems, so they can decide
when to refer on for psychiatric help (a
So far we have mainly discussed the process tricky decision, when specialist services are
of the group, and methods of training. We likely to be scarce). Trainees will be in a
now consider some of the topics which we better position than you to know what is
think you could usefully include (Reynolds regarded as 'normal' and 'abnormal' in their
and Shackman 1993). own culture, and this should be openly
Theories of loss and bereavement are discussed. The stigma of mental illness may
central to work with refugees and displaced prevent many people from coming for help.
people. They will have suffered personal Workers can find ways to encourage people
losses: the deaths of family and friends, the to ask for help after extreme suffering,
destruction of their homes, the loss of without its being seen as illness, or weak-
belongings; and abstract losses: certainly the ness. A checklist for assessing suicide risk in
loss of their familiar life-style, and maybe clients can be useful, as can an analysis of
the loss of beliefs, ideologies, and hopes for the uses (and sometimes abuses) of psycho-
the future. They will be uncertain whether tropic medication. You will want to raise
some of these losses are permanent or trainees' awareness of the more vulnerable
temporary. They will be struggling to make members of the community: for example,
sense of what has happened, to give meaning children, particularly those who are un-
to the appalling events. An understanding of accompanied; women on their own; the
loss and bereavement can help trainees in
elderly,- and those with a previous history of
their assessments. But you need to take into
mental illness.
account that different societies have
An understanding of some of the possible
different ways of dealing with massive
effects of torture and trauma will help
losses and grief, and have their own
trainees to make accurate assessments:
mourning rituals and rites of passage. These
nightmares, lack of concentration, and
are often more collective and community-
flashbacks of traumatic events are often
based than in Western society. Training
experienced by survivors of torture and
should help trainees to recognise commun-
trauma, but are not an indication of mental
ity responses and strengths, so they can
build on these in their work. Many refugees ill-health unless they are seriously affecting
the person's ability to cope.
Tiaining indigenous workers in mental-health care 55

Workers can reassure clients that these from sharing experiences and supporting
kinds of symptom are to be expected after each other (Blackwell 1989; Shackman and
suffering traumatic experiences. If the Tribe 1989). Guatemalan women in Mexico
person is unable to manage daily living tasks City who met as a self-help group realised
and interactions, this is a better indication that they had all been going around thinking
than symptoms alone that a person is at risk 'I'm crazy', when really they were suffering
and extra help is needed (Summerfield the effects of severe political repression and
1992). Often members of the surrounding isolation (Finlay and Reynolds 1987).
community will be easily able to identify You will probably think of many other
those whom they see as 'not managing'. topics: in developing the contents of
Counselling skills, and supportive, training courses, you can make full use of
attentive and non-judgemental listening can your own professional training and skills.
be developed by practice and role-plays. We suggest that you list all the topics you
Trainees can choose or be given case-studies could cover, and what you think trainees
or vignettes and can practise, for example, may want to learn. Make up or adapt
how to approach and talk to a person who is exercises to allow participants to try out
withdrawn and very depressed; how to listen new skills and techniques, and be clear
and respond to someone who is extremely about the teaching points you want to make.
distressed and agitated; how to work with a You probably won't use all of them and,
client's anger and bitter hopelessness about once you find out the needs of your trainees,
the future. you will have to adapt your plans
Exercises and discussions that enable accordingly. It will help you to feel more
trainees to clarify their role and limitations confident if you know you have some ideas
are helpful. This was a topic that took up prepared: a selection you can dip into, a
considerable time on a recent training course varied and filling menu from which you and
which one of us helped to run for Serbo- the participants can taste samples. You will
Croatian speaking workers in the UK, who learn about new approaches and ways of
worked with Bosnian refugees in exile. They working from the trainees themselves.
were beset by demands from clients,
colleagues, and their employing agencies.
Becoming clear about their role and
asserting what expectations they could, or
Constructing an interesting
could not, meet gave them confidence to say
programme
'No' when necessary. Working with clients who may be
Other useful topics could include problem- traumatised and experiencing mental-
solving techniques, interpreter's skills, health problems can be draining, and so can
community development, and working training courses dealing with these issues.
with women who have been raped. (Such Having a variety of topics and exercises will
women are unlikely to come forward for enable you to vary the pace and the
'rape counselling', but might welcome the atmosphere. Sometimes you might want to
chance to be medically examined, and later lighten the tone. Warm-up exercises can be
may want to talk about their experiences or fun, and can have useful teaching points. If
meet with other women who have suffered you have access to video and/or slides, they
in similar ways.) Developing group-work too are useful teaching tools, which give
skills is extremely useful, where numbers participants a break from concentrating on
affected by violence and trauma are large, themselves. Prepared hand-outs give partic-
and where there is a more collective ipants reminders of key points covered.
approach to dealing with grief and loss. Summaries, feedback, and evaluation
People can gain confidence and strength sessions at the end of each day will reinforce
56 Development for Health

what has been done, highlight what Developing a model of training for
participants have found useful, and disclose the future
what the gaps are.
During the training course for Serbo- We hope we have given you some ideas and
Croatian speaking workers we spent time confidence to get started. As you continue
reading poems, singing folk and popular your preparation, it is worth reading
songs from Bosnia, telling jokes, and accounts of training programmes developed
drawing (they produced some vivid group in Latin America which provide models of
pictures representing 'Being a Good Listener'). how work can continue to have effects long
All these activities helped to build a strong after your own relatively brief appointment
group identity, and created a good atmosphere is over. The self-help group we have already
of trust and openness, in which many mentioned with Guatemalans in Mexico
difficult issues were discussed and tackled. City developed a core group of female
mental-health promoters who have continued
We recommend that participants
to work with refugee women and children,
evaluate each training course at the end, so
and to run workshops for others for some
you can develop other courses from a firmer
years after the initial project (Ball 1991). A
foundation. Ask for comments on different
training model that reaches respected members
aspects, including your own style: if you can
of a community can have a 'multiplier'
get people to write down some responses
effect in ensuring that skills and appropriate
before you all disperse, this encourages
methodologies are passed on to others.
some honest feedback.
It is important for the NGOs imple-
menting training programmes in mental
health to integrate this work into longer-
Be prepared for the unexpected term development projects. All too often,
Quite often trainers face the uncertainty of such work is part of a crisis response, when
being unsure how long the training courses what is needed is commitment to support-
will be, or who will attend them. It is likely ing psycho-social programmes over a period,
that you will be required to run a variety of to give continuity with wider-ranging
different courses for both inexperienced and health and community-development plans.
more experienced workers. In addition, you If you can raise these issues with your NGO
may perhaps be asked to act as a consultant at an early stage, you may be able to ensure
to groups or teams of workers. This is a that your work has far-reaching effects on
different role, and you need to clarify what the life of the community.
you are being asked to do. Every training
course is different, but we hope we have
given you some general guidelines. References
If it is possible to work alongside another
trainer, do so, preferably someone who shares Ball, C , 1991, 'When broken-heartedness
language and culture with the participants. becomes a political issue', in T. Wallace and
It is always more productive and creative to C. March (eds.): Changing Peiceptions:
work with a co-trainer, to plan courses Writings on Gender and Development,
together, to deal with difficult situations, to Oxford: Oxfam Publications.
support each other. You will need to spend Blackwell, R.D., 1989, The Disruption and
time developing a working relationship Reconstruction of Family, Network and
with a co-trainer, and even then things will Community Systems Following Torture,
not always go smoothly, but it is time well Organised Violence and Exile, London: The
spent (Reynolds and Shackman, forthcoming). Medical Foundation for the Care of Victims
of Torture.
Buwalda, H., 1994, 'Children of war in the
Training indigenous workers in mental-health care 57

Philippines', Development in Practice, 4 (1): 3-12. The authors


Christensen, C.P., 1992, 'Training for cross-
cultural social work with immigrants, Jill Reynolds is a lecturer at the Open
refugees and minorities, a course model', in University (UK) in the School of Health and
Ryan (ed.): Social Work with Immigrants Welfare. She has provided training for para-
and Refugees, New York: Haworth. social workers and community workers
Finlay, R. and J. Reynolds, 1987, Social from Vietnam and other refugee groups and
Work and Refugees: A Handbook on has developed teaching programmes on
Working with People in Exile in the UK, refugees in social-work professional train-
Cambridge: National Extension College/ ing. Jane Shackman is a training co-
Refugee Action. oordinator at the Medical Foundation for the
Care of Victims of Torture. She does clinical
Freire, P., 1972, Pedagogy of the Oppressed,
work with individuals and families, group
Harmondsworth: Penguin.
work and community development, and co-
Open University, 1993, Roles and Relation-
ordinates the work of the interpreters.
ships: Perspectives on Practice in Health
and Welfare, (K663), Workbook 2, 'Focusing This article was first published in
on Roles and Relationships', Milton Keynes: Development in Practice, Volume '4,
Open University. Number 2, in 1994.
Reynolds, J. and J. Shackman, 1993,
'Refugees and Mental Health: Issues for
Training', Mental Health News.
Reynolds, J. and J. Shackman (forthcoming),
Partnership in Training and Practice with
Refugees.
Shackman, J. and R. Tribe, 1989, A Way
Forward: A Group for Refugee Women,
London: Medical Foundation for the Care of
Victims of Torture.
Summerfield, D., 1992, Addressing Human
Response to War and Atrocity: An Overview of
Major Themes, London: Medical Foundation
for the Care of Victims of Torture.
van der Veer, G., 1992, Counselling and
Therapy with Refugees: Psychological
Problems of Victims of War, Torture and
Repression, Chichester: Wiley.
58

The psychosocial effects of conflict in


the Third World

Derek Summerfield

Introduction instance, 'low-intensity warfare' (so-called


because it is designed to carry low political
According to the UN Department for Dis- risks for its progenitors) has been defined by
armament Affairs, there have been around a Colonel in the US Army Special Forces as
150 armed conflicts in the Third World since 'total war at the grassroots level'. Popula-
1945. Twenty million people have died, and tion, not territory, is the target, and through
at least three times as many injured. In the terror the aim is to penetrate into homes,
1950s the average number of armed conflicts families, and the entire fabric of grassroots
per year was 9; in the 1960s it was 11; and in social relations, producing demoralisation
the 1970s it was 14. Africa in particular and paralysis. To this end, terror is sown not
suffered a dramatic escalation in the 1980s, just randomly, but also through targeted
not just in the number but also in the scale of assaults on health workers, teachers, and co-
wars, some augmented by famine. In line operative leaders: those whose work
with these trends, UNHCR recorded 2.5 symbolises shared values and aspirations.
million war refugees in 1970, 8.3 million in Torture, mutilation, and summary
1980, and currently about 15 million. If the execution in front of family members have
internally displaced are included, the total become routine. Recent events in
doubles. Mortality rates during the acute Mozambique show graphically the stagger-
phase of displacement are up to 60 times the ing extent of personal, social, cultural, and
expected rates. Eighty per cent of refugees economic dislocation which can ensue
are in non-industrialised countries, many of when conflict is pursued along these lines.
them among the poorest in the world. Sixty
per cent of refugees in Africa receive no
assistance.
According to studies undertaken for the The psychosocial effects of
International Symposium of Children and extreme experiences
War in 1983, 5 per cent of all casualties in Human reactions to environmental stress
the First World War were civilians; the have been subject to social and medical
figure for the Second World War was 50 per enquiry since 1900. It is accepted that
cent, and that for the Vietnam war was over individuals in all cultures may react to
80 per cent. In current armed conflicts, over traumatic life events, usually involving loss,
90 per cent of all casualties are civilians, with disturbances of psychological and
usually from poor rural families. This is the social functioning. Summarising many
result of deliberate and systematic violence studies (though mostly in a Western
deployed to terrorise whole populations. For setting), Paykel (1978) concluded that in the
The psychosocial effects of conflict in the Third World 59

months following a traumatic experience seems to have a relatively limited repertoire


there was a six-fold greater risk of suicide, a of responses to major trauma: sleep
two-fold greater risk of a depressive disorder, disturbance, lability of mood (including
and a slightly increased risk of a psychotic sadness and irritability), undue fatigue, poor
illness akin to schizophrenia. concentration, and diminished powers of
For years it was assumed that the memory are common to all these
emotional effects of disasters, natural or formulations. These, I suggest, represent
man-made, were short-lived and minimal. core features which probably appear in all
This is clearly untrue. A study conducted cultures. We are concerned here not with
seven months after an earthquake in transient reactions, but with enduring and
Colombia killed 80 per cent of the inhab- frequently incapacitating states of mind and
itants of the town of Armero showed that 55 body.
per cent of the homeless and 45 per cent of A recent study of 57 Ugandan war
primary-care attenders had suffered signif- refugees (Harrell Bond 1986) concluded that
icant emotional disturbance (Lima 1987). In three quarters suffered an appreciable
a study of the effects of the Bhopal (India) psychiatric disorder. Psychosomatic symp-
toxic gas disaster, 23 per cent of 855 toms (headaches, general bodily aches,
primary-care attenders were identified by exhaustion even when not doing work) were
structured interview as having a definite prominent, as were clinical levels of anxiety
psychiatric disorder (Sethi 1987). The best and panic attacks. Three of the sample were
available comparison of baseline rates in the contemplating suicide, and one had serious-
Third World is a WHO study in four non- ly attempted it. There was a close link
industrialised countries which reported that between depression and the scale of an
around 14 per cent of primary care attenders individual's losses, measured by the number
had evidence of psychiatric disorder of one of people in his or her immediate family who
kind or another (Harding 1980). had died in the war. The researchers used a
Lifton's eloquent descriptions (1967) of cross-culturally validated test during inter-
the survivors of overwhelming catastrophe, views, the Present State Examination. My
like the Hiroshima atomic bomb, record own work with Nicaraguan rural dwellers
how they found themselves changed; they who had contended with the effects of 'low-
experienced a bond with those who had died, intensity' warfare in their daily lives for
and many had great difficulty in re- eight years revealed psychological symp-
establishing trust in others. They had tomatology in approximately half of the
internalised a sense of their own worthless- men and three quarters of the women
ness and powerlessness, like many survivors (Summerfield 1991b). Symptoms were
of great cruelty. Many felt themselves to be similar to those in the Ugandan study. In El
'contaminated' with guilt, as if they could Salvador, at the height of civil war in
somehow have averted or mitigated what 1978-81, psychiatric consultations rose
happened. This kind of guilt is not typically from the eighth to the third most common
experienced by the victims of natural reason to seek medical attention (Garfield
disasters. 1985).
Over the past two or three decades, Anthropological interest in the stresses
researchers and clinicians have summarised facing war refugees is part of a fifty-year
what they saw and heard in survivors of debate on the relationship between mental
extreme trauma under titles like concentra- health and migration, voluntary and forced.
tion-camp syndrome, war neurosis, combat The literature has discussed the sources of
exhaustion syndrome, survivor syndrome stress in terms of loss and grief, social
and, currently, post-traumatic stress dis- isolation, loss of status, and (where relevant)
order (PTSD). In fact the human organism acculturation stresses and accelerated
60 Development foi Health

modernisation. Losses include 'home' in the exposed population manifesting psycho-


widest sense, which includes the surround- logical disorders. Pre-existing personality
ing landscape as the repository of origin factors are obviously capable of shaping the
myths, religious symbolism, and historical way individuals handle such events, but
accounts. With its focus on what has been when there is pervasive mental trauma-
lost, exile or displacement has been likened tisation across whole communities, the
to a kind of bereavement process. These distinctions between individual and
studies record considerable depression and collective traumas may blur. In one report
anxiety, often persistent, psychosomatic there was no significant difference between
ailments, marital and intergenerational ordinary Salvadorean refugees and others
conflict, alcohol abuse and antisocial who had been personally tortured, in terms
behaviour, frequently directed at women. of the severity of psychological
Single refugees, those from separated symptomatology (Aron 1988). This also
families, divorced or widowed women as seemed true in my study of war-disabled ex-
household heads, and refugees in isolated soldiers in Nicaragua (Summerfield 1991a).
situations, lacking company or community, Similar observations have been made in, for
have all been identified as being at higher example, the Armero earthquake disaster,
risk. Some of these issues are particularly mentioned above, and among the victims of
acute for those stranded in camps for politically inspired violence in Northern
months and years at a time. These refugees Ireland. But this area involves complex
must continue to live with the awareness of variables and many studies point the other
a decisive change in their status, from active way, like the Ugandan one cited above.
citizen to a marginal person a war It is a myth, partly propagated by the slant
statistic. There is a pervasive feeling of of media reportage, that in the aftermath of a
ambiguity inherent in camp life. The future catastrophe people will be paralysed and
is uncertain and it is hard to make helpless or break into panic-stricken flight,
predictions. People feel incompetent and or that community function is likely to be
demoralised. Recent WHO-sponsored shattered. Studies of populations under
medical missions to Cambodian camps in bombardment or siege in Lebanon and
Thailand further illustrate why such elsewhere have demonstrated low levels of
conditions are inimical to mental health (de psychological disturbance (Hourani 1986).
Girolamo 1989). This partly reflects the way in which
War victims endure multiple traumas: emotional needs are overshadowed by the
physical privation, injury, torture, incarcer- exigencies of immediate survival, at least
ation, witnessing torture or massacres, and till later. Human resilience is everywhere
the death of close family members. For evident in the conflict zones of the Third
example, Khmer refugees each suffered 16 World. Victims of wars are after all normal
major trauma events on average, three of people, albeit exposed to abnormal forces. It
which constituted torture by UN criteria. is too easy to oversimplify the state of
There are also background factors, not least victimhood, characterising it solely by the
the infectious diseases which flourish in the psychological and social disturbances which
conditions created by war and are can be documented in those affected.
particularly lethal for children. In Uganda Victimhood is seldom 'pure'. Mazur (1986)
the AIDS virus has behaved like a terrorising notes that war refugees are not just hapless
army in its own right, and war-related social victims who have lost everything, but
breakdown is hastening its spread. people who are conscious and active before,
Many studies have indicated that, as the during, and after their flight. He questions
overall severity of a disaster or war whether they are actually helpless or merely
increased, so did the proportion of the labelled so. After all, refugees are survivors.
The psychosocial effects of conflict in the Third World 61

There is also the question of the effects of recollections of the traumatic events, either
sub-nutritional diet on psycho-social in nightmares or in daytime 'flashbacks'.
functioning, which is particularly relevant These may be intense enough to feel as
in Africa, where war and famine have though the traumatic event is being re-lived.
formed a lethal combination. Evidence A disturbed sleep pattern is typical. Another
accumulated from prisoners of war and core feature is hyper-vigilance, often
refugees in World War II suggests that manifested as a tendency to startle easily,
chronic malnutrition contributed to their even in response to minor cues like small
psychological problems. Hunger can have noises. Irritability, restlessness, explosive
pervasive effects upon mood, emotional anger, and feelings of guilt, anxiety and
drive, and social behaviour,- famine has depression may wax and wane. People may
always been known as a time of violation of try to avoid stimuli that recall the fright-
normal human ties. Undernourished ening memories; they may feel detached
children can be less responsive and less able from others, or complain of impaired
to learn. We do not know how much this memory or difficulty in concentrating or
may add to the effects of institutionalised completing tasks. Sufferers do not generally
violence in a country like Guatemala, where experience all features together. PTSD does
up to 80 per cent of the children in some not of course represent a circumscribed
areas are reported to be undernourished. disorder: there is some overlap with the
features of chronic bereavement and in
particular with depressive illness.

Post-traumatic stress disorder It should be emphasised that PTSD as a


(PTSD) descriptive syndrome is generally not meant
to include the intense but relatively short-
PTSD is a formulation increasingly evoked lived emotional distress or disturbance
to describe the psychological responses over which is a natural and immediate reaction
time, frequently years, following exposure to tragedy. Nevertheless, there remain open
to extreme and unusual traumatic events, questions about what might constitute a
commonly wars or catastrophes. It arose out 'normal' range of responses over time to
of work with the thousands of US veterans experiences like being tortured or
of the Vietnam war whose unabating witnessing the shooting of one's child, and
emotional difficulties blocked the route about whether underlying psychological
back to normal peacetime life. Since then, vulnerability or the severity of the trauma is
PTSD has been described in the victims of the central issue (Green 1985). The onset of
terrorism in Northern Ireland, Chilean PTSD can be delayed for months, or even
victims of torture, Cambodian refugees and years, and its effects can last a very long
others. PTSD encompasses the symptom time: some World War n ex-prisoners still
patterns described above in concentration- had symptoms 40 years later.
camp survivors. But most studies have been
I suggested earlier that disturbances of
conducted in Western countries, and rather
sleep, proneness to anxiety, lack of energy,
more on men than women. We know very
and diminished powers of concentration,
little so far about the proportion of civilians
essentially disturbances of arousal and
of a particular population in the Third World
drive, represented universal elements. What
who would react to conflict by developing
of the subjectively experienced emotions
PTSD. My pilot study in Nicaragua
accompanying these indicators of altered
suggested that many of the major features of
body physiology? The emotional distress
PTSD are not uncommon.
felt by a victim, and how it is acted out in
The characteristic symptoms of PTSD are daily life, will be influenced by individual
thus recurrent, painful and intrusive characteristics, but also by social and
62 Development for Health

cultural factors which help to shape the they suffer, and how they adapt. These
'meaning' of the provoking events. For issues are further discussed below, in the
instance, guilt and shame have been section on culture and society.
prominent themes for US veterans of the
Vietnam War, who came home to find that
their society had disavowed the war and was Somatisation
somehow blaming them for it all. Those
who had witnessed the massacre of Somatisation (or psychosomatisation) is
civilians, or participated in the torture of defined, at least by Western clinicians, as
captured Viet Cong suspects, have been the expression of emotional distress in the
especially prone to PTSD. There has been a form of bodily symptoms. Characteristic
powerful association between PTSD and psychosomatic symptoms include recurrent
self-destructive behaviour: since 1975 the headaches, widespread bodily pains, un-
numbers who have died (by suicide, alcohol explained malaise, dizziness, and palpita-
and drug abuse, or shoot-outs with police) tions. Such complaints are just as real and
exceed the 50,000 who perished in the war objective sources of hardship as those that
itself. Men have had great difficulties in might be caused by physical disease or
reassuming pre-war roles as husbands, injury.
fathers, and stable employees. In marked Somatisation is a worldwide phenom-
contrast, 50 per cent of South East Asian enon. However, it has been regarded as
refugees in the USA display symptoms of particularly prevalent in cultures in which
PTSD (and even more are depressed), but expression of emotional distress in a psycho-
there is no associated social dysfunction of logical idiom is traditionally inhibited;
such a violent kind (Molica 1987). perhaps these are cultures which place a
As its name implies, PTSD envisages the high value on interpersonal harmony and
trauma or traumas as finite events, thus implicitly discourage direct expression
completed and receding into the past. But of feeling. WHO studies in various Third
huge numbers of Third World people World countries confirm that psycho-
continue to be exposed to apparently somatic symptoms are very common. And
unending war or State-sponsored oppression published literature on the victims of war in
and must live on in the grip of sustained Latin America, Africa, and South East Asia
states of grief, fear, and apprehension. While all conclude that somatisation is central to
such situations prevail, it is difficult to the subjective experience and the
come to terms with loss. For instance, it is communication of the distress wrought by
hard for a mother to mourn a murdered child violence and disruption.
properly while her other children continue There has been controversy about the
daily to be at risk of the same fate. And while extent to which somatisation can be seen as
threat continues, hyper-vigilance, a core 'equivalent' to depression and, further,
element of PTSD, is actually life-saving whether it is a Western stereotype that
behaviour. I think we need an extended denies the ability of people from non-
formulation of PTSD that encompasses the Western cultures to express themselves in
concept of continuous traumatisation. psychological terms. In fact, war victims
I have considered PTSD in some detail, with psychosomatic complaints often fulfil
because it is so frequently mentioned in Western psychiatric criteria for depression,
current medical literature. But clearly this and some have PTSD. The dominance of
kind of 'medical' model cannot address the somatisation among Asian patients does not
overall complexity of human response to mean that these individuals do not
extreme violence, how people in a particular experience depressive feelings or have no
situation interpret things, how and what psychological insight into their illness; but,
The psychosocial effects of conflict in the Third World 63

some authors suggest, they treat those America in the 1980s have re-appeared
feelings as secondary to their bodily subsequently, or had their exact fates
complaints. Other researchers have found established. It is hard to grieve properly for
that Indo-Chinese refugees readily someone who may not be dead, and even
discussed their symptoms in psychological after years many families are locked into
terms. In Nicaragua I found that rural what has been called 'frozen' mourning.
peasants clearly understood and expressed Their emotional limbo is exacerbated when
the fact that it was the stresses of the war governments even when restored to more
which had generated their somatic democratic forms as in Uruguay, Chile, and
complaints, little of which they associated Argentina refuse to expose the whole
with the pre-war years. Somatisation will truth about such acts, or to lift indemnity
also shape the kind of help that is sought. In against prosecution of those responsible
Nicaragua sufferers were seeking Western (who include doctors). Confronted by a State
(i.e. US) medication, an ironic by-product of which holds on to its dark secrets and which
the war. In Thai camps for Cambodian seems still to insist that the missing are the
refugees, traditional folk healers ('krou guilty ones, it is hard for sufferers to
khmer') have been effective. This is an area overcome a collective sense of helplessness
where complex psycho-cultural realities, and insecurity.
not least those of the researchers, are
operative.
Women in war
In the past the division of labour, the
Torture
allocation of economic obligations within
Torture has been described as a form of the household unit, and the elaborate
bondage by which the torturer ensures that protection built into the marriage system
his interventions will last over time. gave African women more rights than
Victims face the protracted psychological Western feminists assume. But the
problems of other survivors of extreme economic changes accompanying the
trauma, including PTSD, psychosomatic colonial era (and continuing since
ailments, and disturbed body image. The independence) profoundly eroded women's
mere act of survival may bring its own guilt, position in society. Most of the
and they must contend with a pervasive responsibility for food production has come
sense of anguish and humiliation. Like the to rest with them. Throughout the Third
survivors of Nazi concentration camps, they World there seem to be strong links between
must endure what for some is experienced as poverty and households without a male
a catastrophic existential event and rebuild adult. In parts of Central America, 50 per
a new personal identity in a world that can cent of households are headed by women.
never be the same. They may also have lost War, drawing in male combatants and
parts of their body, relatives, work, status, disrupting social and economic patterns,
and credibility. Spouses and children will brings harsh pressures to bear upon
have their own reactions. Reports from women's central role as provider of physical
Chile (CODEPU 1989) convey what a and emotional sustenance for children and
struggle it can be to reconstitute family the elderly. They are even more vulnerable
integrity and openness of communication. when they must take their dependants and
'Disappearances' represent a form of flee. Women and small children comprise
psychological torture for those left behind, more than 80 per cent of the population of
and this is intended. Only a fraction of the many refugee camps and settlements. There
estimated 60,000 people abducted in Latin is concern from various agencies, including
64 Development for Health

WHO and Oxfam, about sexual violence quarters of them had gynaecological
against women in refugee camps, problems, and some were carrying the AIDS
committed either by other refugees or by virus. Half of them had felt unable to tell
camp officials who are in a position to apply their partner (Giller 1991).
coercive pressures. In the Thai camps,
young Khmer women have been attempting
suicide. Accepting that there may be gender-
Children in war
linked differences in the expression of
emotional distress, several studies show 'Low-intensity' conflict in Angola and
higher levels of anxiety and depression in Mozambique during the 1980s has demon-
women than men following both natural strated the consequences for the most
disasters and war in the Third World. vulnerable: the small children. Between 325
Women who have been widowed, have lost a and 375 out of every 1,000 children have
child, or have been raped seem more been dying before the age of 5 (compared
vulnerable to depression and PTSD. with an estimated 185 before these wars),
As a phenomenon, rape is linked to the the highest rate in the world. UNICEF
dynamics of power and aggression, rather estimates that 500,000 extra child deaths
than to sexuality. It is endemic during war, have been directly attributable to war-
and is arguably its least scrutinised and induced destabilisation in these two
documented aspect. Though often seen as countries during the decade. The psycho-
the random excesses of poorly controlled social effects of unremitting violence and
soldiers, it would be more accurately viewed upheaval, here and elsewhere, can intrude
as an instrument of subjugation and brutishly into the normal process of
terrorisation, deployed on a more or less development for an entire generation of
systematic basis. In Latin America perhaps children. The stress and insecurity which all
the majority of women detained on political children can exhibit when separated from
grounds by repressive governments over the their principal carers, notably parents, is
past two decades have suffered sexual grossly exacerbated by armed hostilities and
violation or torture, of which 'ordinary' rape associated population movements. In
is just one form. This has been experienced Angola, for instance, an estimated 300,000
as an attempt to reduce the woman activist children have been orphaned or separated
to the status of 'whore', a traditional symbol from their parents. They may have
of shame in a Catholic male-dominated witnessed the harassment, abduction,
society. In the task of reconstructing their torture, or murder of parents or siblings,
emotional lives, tortured women may face massacres - and the destruction of their
more social and sexual difficulties and be homes and communities. Older children
more prone to suicidal tendencies than may themselves be deliberately killed to
other women whose experiences of brutality prevent them being used by opposition
did not include sexual abuse. They may feel forces,- they may be tortured, or taken away
constrained to stay silent by well-founded for sexual or other forms of exploitation.
fears of stigmatisation within their families There has been forced drafting of children
or wider society. A recent study of 35 into armed units in at least 20 countries on
Ugandan women raped during the civil wars three continents. Worsening economic
of the 1980s showed that years later most of hardship may deepen their feelings of
them still had repeated nightmares about helplessness and insecurity. Children may
the event and felt angry, afraid, and be abused, abandoned, or neglected by
humiliated. Twenty-five per cent now had parents or temporary care-givers, them-
no contact with men, and two thirds had no selves under pressure. Uncertainty and
enjoyment from a sexual relationship. Three tension in a strife-ridden environment
The psychosocial effects of conflict in the Thiid World 65

intimidate indirectly, and thus the preoccupation with their experiences of


collective fears of parents and those of an violence, death, and starvation: pictures of
entire society are added to the normal fears soldiers shooting their mothers, infants
of children. lying bleeding to death, decapitations, dogs
War-traumatised children in any culture eating human corpses, people crouching in
are fairly similar in their emotional and the forests with ribs jutting and bellies
behavioural patterns, which sometimes swollen. A year later these children were
alter only after a latent period. Pre-school still drawing like this, almost always from
children may show frequent or continuous first-hand experience (Harrell Bond 1986).
crying, clinging dependent behaviour, bed- There must be distorting influences bearing
wetting and loss of bowel control, thumb upon the socialisation of the young in
and finger sucking, frequent nightmares and societies where force appears to be the only
night terrors, as well as unusual fear of means of conflict-resolution, and where life
actual or imagined objects. They may seems to be little valued. They too may
regress to an earlier developmental stage. accommodate themselves to violence. Even
Children of early school age can have these very young Ugandan children, when asked
features too and be overtly unhappy, about their aspirations for the future, talked
nervous, restless, irritable, and fearful. of bloody revenge. On the other hand, a
There may be self-stimulation such as UNICEF-funded study of child stress in
rocking or head-banging. They may not Uganda interviewed 74 who had been
want to eat, or they may have physical recently evacuated from the Lowero
complaints headache, dizziness, triangle, the 'killing fields' of Uganda. Only
abdominal pains with a psychosomatic two identified with armed aggression, and
basis. They too can regress to behaviour the rest said that they wanted to help groups
appropriate to a much younger child, in like the Red Cross who had helped them
some cases to prolonged muteness or to bed- (UNICEF 1986). We cannot generalise.
bound incontinence as if they were babies. In urban South Africa, politicised black
They frequently have particular fears: of young people often reject the norms of their
being left alone in a room or sleeping alone, parents, dismissing their pious hopes for
or of situations which carry some reminder peace as undue capitulation to the apartheid
of the traumatic events they have witnessed. state. Perhaps what is being said implicitly
The social behaviour of traumatised is that parents have failed to protect their
children can be markedly affected, some children from the oppressive State, so that
becoming extremely withdrawn and they must now fend for themselves through
mistrustful, others loud and aggressive. activism, including violence. Thus it is that
They may have learning problems. dominant authoritarianism can undermine
Adolescents can behave similarly, though benign authority, like parenthood. Inter-
their responses may be shaped also by generational tension of this kind has been
whether they have passed the age deemed in described elsewhere. But it is also worth
their particular culture to mark the onset of noting that young people picked up at
adulthood. random on police sweeps may be less able to
War-related themes weave their way absorb the effects of arbitrary detention and
insidiously into the mental lives of exposed ill treatment than those whose political
children. A study of 3-9 year olds in Lebanon understanding and commitment affords
discovered that war was the major topic of them a 'meaning' for what has happened to
conversation for 96 per cent of the children, them.
of play for 86 per cent, and of drawing for 80 A study of children living in the conflict-
per cent (Abu-Nasr 1985). The drawings of affected areas of Northern Ireland concluded
Ugandan refugee children show their that psychological disorders increased
66 Development for Health

noticeably during the 1968 riots and Culturally shaped beliefs about health,
violence in Belfast (Fraser 1974). Children including expectations of the kind of help or
aged 11-12 in conflict-ridden parts of the healing available, determine to a great
Middle East show an increasing incidence of extent how distress is experienced, inter-
serious psychiatric disorder, including preted, and communicated. And though
psychosis and depression leading to suicide physical and psychological distress is
attempts. A follow-up of Cambodian young- experienced individually, it often arises
sters, severely traumatised at ages 8-12, from, and is resolved in, a social context.
found that 48 per cent still had PTSD a Shared supernatural beliefs frequently carry
decade after the events (Kinzie 1989). War explanations and antidotes for mental ill
can have an all-pervading impact on child health, though such attributions may of
development, on the experience of human course provide a basis for the stigmatisation
relations, moral norms, and basic attitudes and neglect of the mentally disturbed. The
to life. social nature of illness, often obscured
within individualistic Western societies,
has been a major theme in the medical
anthropology literature over the past 20
Culture and society years. But despite the complexities of the
In the colonial era it was impressed upon subject, there do seem to be common
indigenous peoples that there were different denominators in human response to war and
types of knowledge, and that theirs was disaster, and there is the universality of
second-rate. The emotional and social lives bereavement as a life event, understood and
of subject peoples were defined in terms of dealt with by all cultures. There are
European priorities, and the responsible similarities in the psychological symptoms
pursuit of traditional values was usually and adjustment problems shown by Western
regarded as evidence of backwardness. survivors and by those from widely
Subscribing to the prevailing cultural disparate non-Western cultures, as
assumptions, and perhaps also to an implicit discussed earlier.
belief that mental ill health was part of the Major events impinge not just upon
price that Judaeo-Christian peoples had to individuals but at the level of the whole
pay for 'civilisation', colonial psychiatrists society. Even if war-free, most Third World
thought that mental illness was rare in societies are facing rapid change. The
native populations. In the post-
colonial era initiated processes tending to
independence era, other psychiatric
the rupture of cultural continuity the link
researchers have documented that
between past and present and these have
depressive illness was common, for instance
been continued in the name of
in Africa, and that anxiety in its various
modernisation since then. Rural life has
forms was as prevalent as in Western
been depleted by the drift to the urban
societies. But the relativity of knowledge is
centres as the result of crop failures and
nowhere more central than in areas
patterns of unjust land ownership. That
encompassing feelings, beliefs, and
traditional family and social structures are
behaviour, and it has generally been non-
psychiatric researchers who have under stress as never before is evidenced, for
emphasised the limitations of Western example, by the rapid increase of alcohol-
categories of mental disorder for organising related medical, social and economic
our comprehension of what those in non- problems in the Third World. Indeed, one
Western cultures experience. study reported that 18-40 per cent of high-
school students in Nigeria were consist-
Even concepts like 'stress' and 'coping' ently abusing alcohol (Oshodin 1980). The
are bound by culture and, indeed, by class. struggle between old and new forms at a
The psychosocial effects of conflict in the Third World 67

time of economic stagnation must render emotional responses to hunger, extreme


societies vulnerable and volatile. Alienation poverty, and oppression through the
in the face of Westernisation, which has not metaphor of mental disorder ('nervous-
delivered what it seemed to promise, can ness'). This is a tragic rationalisation, but in
arguably be linked to the rise of Islamic and a climate ridden with political violence, it
Hindu fundamentalism in Asia, reactive may be safer to be 'ill' than to name directly
revivals to reestablish coherence and the causes of their predicament. Chomsky
'meaning'. writes that in El Salvador the collective
War or civil conflict can be devastating for traumatic memory of the massacre of
cultural and social forms. In Uganda and thousands of peasants in 1932 was effective
Mozambique huge numbers of destitute and in suppressing dissent for over a generation.
terrorised peoples are haunted by the As late as 1978, whenever peasants began to
memories of the relatives they left unburied, talk about their demands, others brought up
and the supernatural sanctions which will 1932 again. More recently in El Salvador
follow these lapses of mourning and burial there has been a striking resurgence of magic
rituals. The civil war in Sudan has seen practice, from witchcraft to religious sects,
similar society-wide loss of ancestral places among sorely oppressed communities who
and social identity. In Juba none out of 36 seem to need to replace lost 'meaning' in
refugee adolescents, all aged 16, could write their lives. Messianic sects claiming a
a history of their clan. Many did not know mythic invulnerability, most notably in
the names of their grandparents or the Uganda, may be representing something
village their clan came from. Not one could similar.
name any traditional social ceremonies. The It does seem that internalised cultural
traditional cycles of animal husbandry have values and traditional expectations of
not survived the generalised terror, and family life and social roles are important in
most cattle the major currency for social restructuring life after trauma. Adjustment
and cultural interactions related to problems in refugees can be reduced if they
marriage, rituals, and settlement of disputes can join a community of others from the
have been lost. As elsewhere, women are same background. This is also true if the
left exposed. Young women from rural culture of the host country is not too
communities, where prostitution is different from theirs, presumably because
unheard of, have been driven to engage in people in an alien cultural milieu are
this trade in the overcrowded towns. constantly bombarded by messages foreign
Trauma can spawn new forms of to them. African refugees in exile are often
expression, or non-expression, which have anxious to revive their old customs as
in common that they defend psychic well- quickly as possible. In Guatemala, Indian
being, to keep terror and horror out, even if leaders see the preservation of their
such behaviour is not necessarily adaptive linguistic and cultural forms (to the extent
in the longer term. Some of the survivors of of keeping some of them 'secret') as
the Cambodian holocaust of 1975-9, paramount if they are to continue to resist
witnesses to the near-total destruction of State terror determined enough to have
their cultural identity, have coped so far by annihilated 440 of their villages in the early
adopting what has been described as a 1980s. Shared ideas about concepts like
'dummy' personality, a kind of psycho- freedom and justice can obviously provide
logical withdrawal or numbing which for coalescence within societies, as when
allows avoidance of the past. Some say they the majority of the population support a
do not remember what happened. Rural 'just' war. I am in no doubt that many
people in north-east Brazil have come to Nicaraguans were fortified against the
experience and express the physical and psychological impact of the Contra war by
68 Development for Health

what the revolution meant to them in terms mothers. Further identification of traum-
of their history, and the new sense of a atised children may be facilitated by asking
national self which it fostered. None the questions like: 'Do you know any child who
less, in Nicaragua and elsewhere, collective has trouble sleeping at night or who has
healing after conflict must be more tortuous disturbing dreams/nightmares? Do you
when both sides have been drawn from the know a child who cries a lot or who always
same society. seems unhappy or depressed, compared with
When catastrophes are as profound as the others? Do you know a child who won't
Cambodia's, it will take decades or longer talk or seems apathetic? Do you know a
for a society to absorb what has happened. child who won't play with other children or
Those who till now have had to keep their who fights a lot or plays too roughly? Do you
memories locked must be enabled to find know a child who seems to act strangely
words to express experiences that were compared with other children?'
almost literally unspeakable. Some of the What about emotional support and
old traditions and beliefs will not survive healing? In all cultures the healing process
this trial. For individuals, as for a society, occurs through a system of symbols and
things can never be the same and a new rituals, verbal and non-verbal, which are
world view is needed. grounded in the traditional belief systems of
that culture and performed by individuals or
groups whose role as healers is sanctioned
Short notes for mental-health by that society. Certain qualities of healers
promoters in traumatised and the healing process have been
communities universally identified as central to their
efficacy, including communicating the
Who are the most vulnerable? Members of expectation that symptoms can be relieved,
the community are likely to have a good idea conveying a knowledgeable manner,
of those among them who are most drawing together key persons valued by
preoccupied with their terrible experiences those in distress, and generating hope for an
or who are generally a source of concern. improved existence. A primary health-care
Familiarity with the common presentations worker or mental-health promoter who
of traumatisation, for adults and for seeks to intervene in traumatised
children, is needed. It is likely that people communities needs first to be acceptable to
without family support, or women who everyone and alert to cultural issues where
have lost a child or spouse, are more at risk. they arise. A warm, sympathetic, and non-
It has also been shown that feelings of judgemental manner is essential, and he or
worthlessness, or the feeling that one is she also needs to be clear that listening
unable to play a useful part in life, or the self- means bearing witness, and that this is not a
perception of poor emotional or physical
useless activity. It may be very hard for
health status are all strong predictors of
people to communicate their experiences,
psychological disturbance in victims of
and the worker, whether in a one-to-one
major trauma. Social dysfunction like self-
interaction or in a group, can help to create
neglect or child-abuse is also a definite
an enabling atmosphere in which people can
indication. These guidelines may also
share not just the hard facts of their stories,
identify the most vulnerable children,
but also their feelings. It is important to
because their emotional status during war
allow intense emotion to be expressed
has been shown to be strongly linked to that
without a sense of shame. Signs of
of their principal care-givers. Children can
weather much more if they do not detect helplessness and low self-esteem may
particular panic or depression in their emerge, as well as the anger and guilt which
are inherent in grieving processes. People
The psychosocial effects of conflict in the Thizd World 69

may need realistic assurances that their consistent with the objectives of non-
feelings are normal responses to extra- government organisations (NGOs) in
ordinary events beyond their control and do relation to the enhancement of human
not reflect personal weakness. Thus through rights and social justice. Further, the
discussion people can come to a better collective testimony of people who have
understanding of their feelings or been traditionally voiceless is also a writing
symptoms, including the link between war- of the history of the times. Wars create
related stress and their bodily ailments. effects which can far outlast them, and
Groups, whether focused on discussion or follow-up over years is surely a priority.
on a practical task, also allow individuals to How will the lives of a generation of
overcome the sense of isolation which so Mozambican orphans who witnessed the
often accompanies serious emotional murder of their parents shape up over the
distress, and allow individuals to draw next decade? Monitoring the effects over a
strength from the opportunity to give long period should be a priority for NGOs
something of value to others. The worker and, indeed, of governments themselves.
can help people to talk through some of their The business of documenting is also a
problems, but should not offer instant practical intervention. Just as the gradual
solutions. Attention can be drawn to the recounting of the trauma story may be
ways in which people are once again essential to the individual psychotherapy of
bringing their lives within their control. a torture victim, so too assisting the process
by which the traditionally voiceless come to
be heard is of itself empowering. Naturally
there must be no unmodified importation of
Concluding comments Western psychological 'expertise'. Com-
Most conflict in the Third World currently munities must be understood in terms of
involves terrorisation and deliberate their own dominant conceptions of mental
attempts to produce psychosocial injury. health and ill health. Given the variety of
Keeping this core psychological dimension forms of co-operative efforts in the Third
in mind affords us better chances for World, definitions of self-help will vary.
accurate empathy with those affected, for Indeed, we are often dealing with dynamic
tracing their responses over time, and of situations in which traumatised
course for assisting in the processes of communities actively evolve new forms of
recovery and regeneration. self-help and assertion. Community
These psychosocial consequences are participation can be encouraged, but not
part of the record of what actually happened prescribed. Local people must basically
in any particular conflict, no less real or choose their own priorities and be
substantial than the statistics about the empowered to act on them. The recovery of
numbers of dead, homeless, and hungry. a sense of autonomy is obviously good for
Psychological traumatisation is an actual mental health. Thus projects aimed at
experience, and victims everywhere need psychosocial healing would invoke may of
recognition of this. At the same time, I think the non-material objectives of social
we should focus on traumatisation not development and education, as NGOs
primarily as an injury which a particular define them. With raised awareness,
individual may or may not have sustained, previously unanticipated psychosocial
but instead as a process or processes benefits may be spotted in apparently
impinging on social and cultural organ- unlikely-looking projects whose official
isation at various levels: family, commun- goals were quite different.
ity, and society. Assisting a more complete Human-rights bodies, churches, or any
counting of the human costs would be other organisation able to monitor and
70 Development for Health

document the on-going personal and social because of their heightened vulnerability
impact of conflict need support and during war and their central role as providers
encouragement in this function specifically, and nurturers, not least as emotional shields
as well as for the direct assistance they offer for their children. Projects that target
victims. And we need to be alive to the ways women offer a way in to the mental health of
in which trauma-related mental-health the whole community.
work of the kind outlined earlier might be The question of monitoring projects will
made available to a community, tailored to not always be easy, not least because in the
their particular situation. Mental-health mental-health field outcomes may be hard
training for primary health-care workers, to quantify. Moreover, in dynamic and often
the training of refugees as mental-health unstable situations objectives may shift in
promoters, the preparation of audio-visual mid-project. Means of evaluating progress
material which could be delivered in the must be culturally appropriate.
schoolroom, clinic, church, or other facility If NGO field staff are to attend to this
are all approaches to enable individual and emotive and pain-ridden realm more
collective handling of the core themes: fear, closely, they may have to cope with higher
unresolved grief, the problem of disappeared levels of stress. They may also have to con-
loved ones, stress-related physical ailments, front more professional dilemmas and even
alcohol abuse, abandonment by spouses, risks, particularly in countries whose
sexual abuse, and cultural threat. governments directly or indirectly propa-
One universal theme in human responses gate violence, and where community health
to extreme events is the crucial role of social and social-welfare projects are regarded as
networks in aiding recovery. Harrell Bond subversive.
(1986) comments that aid has often not been
applied to maintaining social institutions.
War victims are expected to cope by being Postscript1
appropriately 'social', but may not have the
resources to re-establish the real bases of If the domain of psychosocial projects has
social life. It seems fundamental that emerged from increased awareness of the
anything that can help to reconstitute human dimensions of conflict, one
family and kinship ties, and social and unfortunate aspect has been the 'discovery'
cultural institutions, must be good. There of 'trauma' and 'post-traumatic stress'. In
might be opportunities to extend the current recent years, trauma projects have had a
range of social-development projects to sharply increasing profile in emergency-
serve these ends. For many peoples there is relief work, with their proponents claiming
considerable reparative power in ritual, that huge numbers were affected, that local
traditionally central to the struggle to retain workers were overwhelmed, and even that
the sense that there is order in the universe. such work could prevent subsequent wars
by tackling 'brutalisation'. It is worrying
Traditional healers can play a role here.
that such expansive and fanciful claims
There will be circumstances when early
could come even from consultants to
intervention, perhaps on a one-off basis, is
UNICEF, WHO, and UNHCR. Trauma
needed: the provision of material for burial
projects have attracted considerable fund-
shrouds obviously qualifies here. There may
ing, despite lack of evidence that war-
be healing resources in other socio-cultural
affected people see their mental health as a
forms like music, drama, or dance.
priority issue, to be addressed separately
Particular groups should be considered for
from their other concerns, and still less that
targeting: orphans, the elderly, the
they would want it done in projects
physically disabled, those mutilated by conceived and led by outsiders. It is a serious
torture. Women should be a particular focus
The psychosocial effects of conflict in the Third World 71

distortion to re-label the suffering of war as a natural disasters, always throws up: societal
psychological condition 'trauma' as if acknowledgement, reparation, and justice.
it were a technical problem to which a short- Keeping these at the centre of operations
term technical solution called 'counselling' may well be a test of the nerve of NGOs, not
could be applied. Counselling is a cultural least in respect of their charitable status, but
product as Western as Coca Cola, and is at they cannot be ignored.
odds with most non-Western psychological I have discussed these issues at length: see
frameworks and concepts of mental health. the annotated bibliography at the end of this
There is a danger of perpetuating the volume.
colonial status of the Third World mind.
Trauma projects ignore (and indeed impede)
people's own traditions, skills, and
approaches to crisis, and pay only lip-service
Note
to the priorities they deem most urgent. 1 Added in 1996.
There is a question of power here. The
current fashion for such interventions not
least in Bosnia and Rwanda owes
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11 Development for Health

frequency in four developing countries', The author


Psychological Medicine, 10:231 -41.
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high school students in Benin City, Nigeria',
Drug and Alcohol Dependence?: 141-5.
Paykel, E., 1978, 'Contribution of life events
to causation of psychiatric illness',
Psychological Medicine, 8:245-54.
Sethi, B. et al., 1987, 'Psychiatric morbidity
in patients attending clinics in gas-affected
areas in Bhopal', Indian Journal of Medical
Research Supplement, 86:45-50.
Summerfield, D. and F. Hume, 1991a, 'After
the War in Nicaragua: The Continuing
Impact of Physical Injury and Disability. A
Psychological Survey in Two Communities'
(in preparation).
Summerfield, D. and L. Toser, 1991b, '"Low
intensity" war and mental trauma: a study
in a rural community', Medicine and War, 7:
84-99.
UNICEF, 1986, Children In Situations Of
Armed Conflict.
73

Financing primary health care:


an NGO perspective

Patricia Diskett and Patricia Nickson

The problem poor-quality services, and chronic shortages


of supplies, especially of drugs. It seemed
Since the World Health Organisation's com- that 'health for all' would remain an ideal,
mitment to primary health care (PHC), rather than become a reality.
declared at Alma Ata in 1978, PHC has been
Governments in the South found them-
adopted by most governments as a strategy
selves under growing pressure to increase
through which they could achieve 'Health
their investment in health, in order to meet
For All By The Year 2000'. The aim was to
growing demands on services and increasing
develop appropriate PHC systems that
health needs. Yet at the same time, the
would be widely accessible and sustainable
World Bank and the International Monetary
at a level which poor communities could
Fund wanted those governments to cut
afford. Community participation (including
public expenditure as a part of wider cost-
participation in decision making) was ident-
saving exercises, often linked to economic
ified as a key strategy through which PHC
readjustment programmes.
could be implemented. But this was often
interpreted to mean merely community The conflict between ideology (health for
contributions (providing financial support all) and reality (acute funding problems,
and resources such as voluntary labour). poor-quality services, and low coverage) led
many governments to conclude that 'free'
By the mid-1980s it was apparent that the health care was no longer a viable option.
costs of implementing PHC had been under- Faced with this dilemma, they favoured the
estimated. It seemed unlikely that there philosophy of charging for health care, for
would ever be enough public money avail- several reasons: it apparently provided them
able to meet all demands for health services. with a partial solution to their financial
Many countries found themselves in severe problems, and allowed them to reduce some
economic difficulties, due to a combination of their commitments (or over-commitments)
of factors, including debt repayments, a drop in the public sector. It lessened the need to
in world market prices for cash crops, natural face the harsh realities of re-allocating
and man-made disasters, civil unrest, and resources between and within Ministries.
military expenditure. And it capitalised on the existing practice of
So, almost at the mid-point between the paying for some health care through direct
Alma Ata declaration and the year 2000, the household expenditure (for example, on
issues of financing PHC assumed increasing traditional remedies, private practitioners
importance. Many people still did not have and pharmacies, and traditional healers).
access to PHC. State services were often Meanwhile, multilateral agencies, like
underfunded, which led to poor supervision, the World Bank1 and UNICEF, were finding
74 Development for Health

that increasing proportions of their budgets PHC, but in a deteriorating economic situa-
were tied up in covering the recurrent costs tion few options were open to them. The
of existing programmes and projects. This Bamako Initiative was adopted, supported
limited the opportunities for new initiat- by WHO and UNICEF. It aimed to tackle
ives. Governments were unlikely to be able some of the problems associated with
or willing to take over these running costs, sustaining and financing PHC programmes.
so recovering some or all of them from Specifically it attempted to address the
communities seemed to provide the answer. shortage of drugs at local health centres and
It should also be noted that the renewed peripheral health posts. The idea was that
interest in charging for health care seemed income would be generated by imposing
symptomatic of current external (Western) charges for drugs, and by introducing
economic policies, and was linked with the revolving funds to pay for drugs. The aim
trend to push responsibility back on to the was to contribute to recurrent expenses
consumer. The support of external donors such as drug costs, health workers' salaries,
for the notion of cost recovery, through fuel, other consumables, and transport.
schemes such as the 'Bamako Initiative'2 In its original form, the Initiative
(see below), seemed to legitimise this trend. generated considerable controversy. There
While international donors were re- was concern that its focus on the sale of
discovering the idea of charging, many non- drugs would undermine the WHO's policies
government organisations (NGOs) and on the use of essential drugs, by encouraging
small projects were having to come to terms over-prescribing and irrational drug use.
with some harsh facts. For many years they This was a particularly valid concern in
had tried to support their work through 'user programmes where drug sales were linked
charges' (charges for services) and commun- directly to health workers' salaries.
ity financing schemes, yet were unable to However, the Bamako Initiative Manage-
sustain projects at a level which the ment Unit (BIMU) of UNICEF has since
community could afford without contin- revised some aspects of the programme.
uing external support. In addition, many Despite its many apparent flaws, the Initiat-
people, usually those most in need, would be ive was a pragmatic attempt to address a
excluded by their inability to pay, without fundamental issue which still remains: how
exemption schemes and subsidies. It to finance and sustain health care in the face
seemed that the international community of considerable economic constraints?
had failed to learn from the experiences of
NGOs and small projects.
There remains the chronic problem of Learning from experience
funding government health care from public
funds, in the face of growing needs and Concern over the implications of the
demands on services. At the same time there Bamako Initiative prompted an international
is an increasing recognition that many conference on Community Financing which
NGO-funded projects are not sustainable was held in Freetown, Sierra Leone in 1989.
without continuing external support. Organised jointly by NGOs (Health Action
International and Oxfam UK and Ireland)
and UNICEF, it brought together over 70
participants with wide-ranging experiences,
The Bamako Initiative from those involved directly in community
African Health Ministers met in Bamako, programmes to policy makers and research-
Mali in 1987, to discuss the problem of ers. The conference aimed to enable partic-
financing primary health care. They ipants to learn from recent experiences and
resolved to raise additional resources for to look at key areas of concern:
Financing primary health care 75

the Bamako Initiative; fees for services given, or fee per consult-
equality (equal access to health care for ation;
equal needs); drug sales and revolving drug funds;
alternative forms of health-care finance; personal prepayment schemes (insur-
community participation; ance);
problems of foreign exchange and the income-generating schemes (community
need for continuing financial resources; or individual labour/fund-raising activ-
the rational use of drugs. ities/festivals/raffles/donations, etc.).

A full report was produced,3 with specific The following observations are based on a
proposals and recommendations, covering selective review of some Oxfam-funded
issues of concern for policy makers; projects in Asia, Latin America, and Africa.5
operational problems in implementing Oxfam funds approximately 500 health
community financing schemes,- operational projects worldwide. About one quarter of
research needed for planners and implem- them were reviewed briefly (through grants
enters; and some practical suggestions for lists, documentation, and project files).
alternative forms of community finance. Approximately 30 projects were reviewed in
Since the conference, there have been detail, through scrutiny of files, project
several formal and informal discussions and visits by researchers from the Liverpool
meetings.4 However, there was a consensus School of Tropical Medicine (to Chad, Zaire,
that, while the Bamako Initiative had been and Uganda), and discussions with staff
designed to meet a specific need, the visiting the UK.
underlying cause which created that need
had not been adequately addressed.
There is still concern that governments
Charging systems
will need to make continuing and increasing Many Oxfam-funded projects operate a
commitments in order to address the health- variety of user charges, usually with a
financing crisis. Considerable support from system of exemptions. Despite that, such
external donors will be needed, on a long- projects tend to be regressive, for several
term basis, if the burden of international reasons: first, the sick are penalised in rela-
debt, and the costs of maintaining services, tion to those enjoying good health. More-
are not to fall on poor communities who can over, the poor pay more, because they are at
least afford to pay. Cost-recovery schemes greater risk of being sick. When standard
(recovering costs from communities) will at charges are used, as they often are, health
best be only a 'first aid' measure. care costs the poor a higher percentage of
What then is the role of NGOs and project their annual income than it costs the
partners in the current situation? Let us wealthy. Thus some potential clients are
consider some of the experiences of NGOs excluded by their inability to pay. Where
(in this case, Oxfam) which were shared at exemption schemes operate, their effective-
the conference. ness is often not routinely monitored.
However, most projects using these
charging systems depend on them for their
economic survival. Many would argue that
Cost-recovery and community
free health care would lead to poorer-quality
financing: the Oxfam experience
services, or none at all, and that
Oxfam's experience (past and present) is communities would be even worse off.
almost exclusively at the community level. It is difficult to maintain a balance
It covers a range of different methods, between recovering enough costs for the
including the following: project to be viable and yet keeping the costs
76 Development for Health

low enough to avoid deterring potential local level, especially when health workers'
users. It is not possible to recover all costs if salaries are linked to drug sales or profits,
services are to remain affordable. Criteria for and project or community control may be
a more appropriate charging system would weak. Yet another problem is the definition
include the following: of essential drugs and the prescription of
non-essential drugs.
the development of an exemption system,
The problem of decapitalisation seems to
agreed between communities and
be very common:
projects, which is then monitored;
an emphasis on charges per sickness One scheme in Zaize developed an
episode or consultation (rather than the innovative and seemingly successful way of
actual cost of treatments or drugs); dealing with this. As soon as the
operational research (to investigate who pzogiamme had enough money, it bought
uses/does not use the services and why) cattle. When it was time to buy a new
which can be used to modify the system consignment of drugs, the cattle were sold.
in favour of the disadvantaged. This meant that assets were not held in
cash, which tended to lose real value, but in
the form of livestock, which generally
Drug sales and revolving funds retained a constant real value.6
Many projects charge the actual price of the
drug, with a percentage added on to cover However, such innovative (and sometimes
transport costs, handling, inflation, etc. risky) solutions are the exception rather
Others calculate a standard charge which than the rule.
can be applied across the board to all items; In summary, these schemes do seem to be
this may increase the cost of some normally successful in improving drug availability,
cheap items, such as aspirin, in order to when certain guidelines are followed. They
subsidise others, such as rifampicin. cannot, however, be expected to subsidise
other areas of health work, such as the
The advocates of revolving drug funds
training of community health workers,
stress their many advantages: the improved
immunisation programmes, or preventative
availability of drugs can lead to better use of
activities. Too much emphasis on profit
facilities and improved quality of treatment;
would detract from the aim of making
revolving funds, it is said, generate income
essential drugs available at low cost.
and guarantee regular drug supplies; through
careful budgeting it is often possible to Criteria for viability seem to include:
provide free or subsidised drugs to the poor; the development and use of a rational
and dependency on ad hoc donations of drug policy (including guidelines on how
(often inappropriate) items can be avoided. to use drugs safely and appropriately);
However, considerable problems are also use of a standard list of essential generic
noted. Calculating profit margins is drugs;
complicated by management problems, development of standard treatment
such as having to budget for inflation, rising guidelines,-
prices, foreign-exchange transactions, good management, administration,
devaluation, import charges, and taxes. monitoring, and reporting;
Many Oxfam-funded pharmacies depend on good control and monitoring at project
having skilled administrators to run them, and/or community level;
and even then find themselves decapitalised staff training with adequate support and
after three-five years, due to such problems supervision;
as those mentioned above, which are usual- accurate price setting (which reflects the
ly beyond their control. Another frequent need to subsidise some more expensive
problem is the opportunity for corruption at drugs), or, better still, a standard charge
Financing primary health care 77

per consultation rather than per There seem to be several advantages in


prescription; such schemes. First, they are more favour-
an exemption scheme; able towards the sick and poor. Risks are
a guarantee of foreign exchange if drugs shared, so the system is progressive rather
are tribe imported. than regressive. Patients are not penalised at
their most vulnerable time, when they are
sick and perhaps unable to work. As
Personal prepayment schemes premiums are usually set annually, the
(insurance) project can depend on a certain level of
This kind of scheme has featured more income; this facilitates budgeting. Finally,
prominently in Oxfam projects in Asia than annual payment of fees can take into
in Africa. In the projects, services are usually account seasonal variations in members'
paid for in advance of need, which may bear ability to pay; for example, more money is
no relation to service use. Costs are shared usually in circulation after the harvest.
out among individuals, regardless of However, membership levels often
whether they use the services or not; so the remain low, because many people may be
healthy subsidise the chronic sick. unwilling to pay in advance for a service
Oxfam used to fund Gonoshasthya Kendra which they may not use. In addition, it is not
(GK), the People's Health Centre in Bangla- usually possible to cover a sufficient
desh, which operated an innovative scheme. proportion of costs by this method alone.
In 1976, GK instituted a system of prepay- In summary, this is one of the most
ment which divided members into classes: progressive methods so far discussed, yet it
is the one of which we probably have the
The destitute/no male earner/disabled
least experience or knowledge. Some
earner: these paid a registration fee of 5
criteria for viability can be deduced:
taka each year, and 1 taka per visit.
Families who could not afford, from any There needs to be good understanding of
source, two meals a day: these paid 10 the community dynamics and
taka a year to register, and 3 taka per visit. community coherence, because some
Families who could afford two meals a members of the community will have to
day throughout the year, but had no subsidise others, with seemingly few
surplus: they paid 25 taka a year, plus 6 benefits for themselves; considerable
taka per visit. preparatory work needs to be done in the
Wealthy landowners paid 30 taka a year, community before such programmes can
plus 5 taka per visit, plus half the cost of be contemplated.
the medicine. Membership should ideally be broad.
Premiums must be affordable, and ideally
Non-members could still have access to the on a sliding scale.
services by paying 10 taka per visit and the
total cost of the drugs or treatment. There
were also different charges for a long list of Income-generating schemes
services such as investigations. These schemes are often based on
About 25 per cent of those eligible were community labour. In one project in
said to have enrolled in the scheme. Senegal, villagers developed several differ-
Membership renewals, however, were quite ent income-generating projects to support
low. Overall, GK recovered approximately their local health posts and health workers,
50 per cent of its cost, through fees for and develop water supplies. These included
services and the insurance scheme (roughly the sale of vegetables from market gardens,
25 per cent from each). and the purchase of chairs and tables for hire
at weddings and funerals. The latter
78 Development for Health

involved the development of a women's not be a priority for the project itself. One
fund-raising committee to control the way to reduce this risk might be to develop a
finances and activities. diversified funding base. However, external
Such activities have made useful contrib- NGOs and major donors often play a valu-
utions to health programmes, but they cover able role in giving projects access to foreign
supplementary needs rather than core exchange (sometimes their only access).
financing. They all require a great degree of
community participation, and in some cases
have led to disharmony, with some mem- A possible role for NGOs
bers resented for not doing their share of the
work. While fairly successful on an ad hoc An underlying aim of many health and
basis, this is not a reliable method of financ- development projects is self-sufficiency.
ing, because it is difficult to sustain over a The theory is that projects have a greater
long period. It is, however, extremely useful chance of success when there is community
when funds are required for a specific involvement in decision-making and in
purpose, such as repairs to a health station. community contributions. However, recent
experiences in the health sector7 support
Oxfam's own observations that some degree
Conclusions of self-financing which reduces dependency
It seems that most projects currently use on donors and governments is necessary, but
more than one method of funding in order to total self-sufficiency is neither possible in
contribute towards their recurrent costs, to the current economic climate nor desirable,
purchase basic drugs and medical supplies, because higher charges would be needed,
to supplement health workers' salaries, fund which would penalise too many people.
community health workers, construct and This is not compatible with the aim of
maintain facilities, and support specific equality, on which the whole philosophy of
elements of the programme, such as primary health care is based.
supervision costs. One option for NGOs is to make longer-
Most schemes seem to have some mech- term funding commitments to health
anism for enabling the poorest to claim free programmes than has currently been
treatment, although there is little evidence popular. This will mean acceptance that
of the effectiveness of such schemes. some projects may need support and
The most common methods used subsidies over a ten-year period, or longer, if
globally in Oxfam-funded projects are fees they are to maintain their current pro-
for services, and revolving drug funds. grammes. It also implies a willingness to
Insurance schemes and prepayment work more closely with governments on
schemes are progressive and offer interest- developing services in countries where
ing opportunities for greater fairness, but infrastructure is weak, health status poor,
they are few and far between. Other and poverty levels high.
methods are useful as supplements, but will NGOs must accept that prevention and
not in themselves generate sufficient funds. cure go hand in hand. While poor people may
Few projects are able to survive without be prepared to contribute to the costs of
continuing external support in some form or curative care, it is unrealistic to expect them
another, despite attempts to promote self- to share the burden of all preventative
reliance. Projects whose main source of activities. These will continue to need sub-
funding is one single donor are extremely sidies from projects and NGOs. NGOs must
susceptible to policy changes by that donor, also accept that sharing costs with
and cannot always resist the donor's communities (asking them to bear part of
pressure to undertake activities which may the costs in cash or kind) will continue to be
Financing primary health caie 79

an integral part of many NGO-funded Notes


projects. But total cost-recovery or self-
sufficiency is neither a possible nor a 1 David de Ferranti: 'Paying for Health
desirable aim. NGOs need to develop clearer Services in Developing Countries', World
guidelines for field staff and projects, and Bank Staff Working Paper No 721,1985.
provide a range of workable options which 2 UNICEF Executive Board: 'Revitalizing
will protect the interests of the poor. PHC/MCH. The Bamako Initiative',
The option of free health care for all, Progress Report E/ICEF/1989/L.3; and
while it may be an ideal, unfortunately 'Guidelines for the Implementation of
would not be workable in the current econo- The Bamako Initiative', 38th session of
mic climate, nor is it compatible with the the Brazzaville Regional Committee,
policies of many governments, which must September 1988, document No
adopt pragmatic solutions to their economic AFR/REC38/18Rev. 1.
problems. In many poor countries, 'free 3 UNICEF, Health Action International,
health care' means no health care. and Oxfam: 'Report on the International
The most appropriate philosophy for Study Conference on Community
NGOs is perhaps to encourage cost-sharing Financing in Primary Health Care held in
between NGO, government, project, and Freetown, Sierra Leone', September 1989.
community. This would avoid placing the 4 Patricia Nickson: 'Bamako Initiative'
burden of all costs on individuals, and would (Conference reports), Essential Drugs
recognise that communities cannot be Monitor No 9-1990, WHO, Geneva, pp. 7
expected to provide the answer to current and 12.
economic problems, but can participate in 5 Patricia Diskett: 'Financing PHC: A
the development of programmes which Selective Review of Oxfam-funded
benefit them directly. Emphasis on such Health Projects', internal report, Health
cost-sharing will not address national-level Unit, Oxfam UK and Ireland, 1990.
inequities, but, if sensitively applied, can 6 Catriona Waddington and Patricia
help to redress the balance locally. Nickson, Liverpool School of Tropical
It seems that NGOs have an important Medicine: 'Drug Sales: A Solution to the
and continuing role to play in sharing "Sustainability of PHC"?', paper
information and the results of research; presented at the Sierra Leone conference.
exploring alternative models of cost-sharing 7 Thomas }. Bossert: 'Can they get along
and financing; monitoring the effects of without us? Sustainability of donor-
programmes on partners and beneficiaries; supported projects in Africa and Central
strengthening PHC structures and manage- America', Social Science and Medicine
ment at different levels, and promoting Vol. 30, No. 9, pp. 1015-23,1990.
decentralisation in a hostile economic
climate; and engaging in advocacy and
lobbying alongside project partners. The authors
NGOs which work with the poor need to
At the. time of writing, Patricia Diskett was
retain a watching brief, monitoring the pol-
a Research Fellow in the Department of
itical environments in which programmes
International Community Health, Liver-
operate, and their effects on the poor and on
pool School of Tropical Medicine. Patricia
project partners. They have a role in encour-
Nickson was a Health Adviser to the
aging international donors to address the
Christian Medical Commission (Geneva),
international issues and underlying crisis
and Lecturer at the Liverpool School of
a role which goes beyond merely applying
Tropical Medicine. This article first
'first aid' treatment such as cost-recovery in
appeared in Development in Practice
the health sector.
Volume 1, Number 1, in 1991.
80

Population control in the new world order

Betsy Haitmann

As someone who believes strongly in Population control is also vitally linked to


women's right to safe, voluntary birth 'free market' economic strategies. The
control and abortion and who is deeply break-up of the Eastern bloc, the controlling
troubled by attacks on that right by influence of the International Monetary
conservative forces I am equally con- Fund (IMF), the World Bank and other
cerned about the ways in which international financial and corporate
population-control programmes can violate institutions, and the corresponding decline
basic human rights and can be a form of of national sovereignty have led to a
violence against women. systematic reduction of public spending on
human welfare. Since the benefits of the free
market rarely trickle down to the poor, then
The intensification of population the only way of reducing poverty, the logic
control goes, is to reduce the number of poor people
being born. If women have fewer children,
In the so-called New World Order, the Cold they also form a better reserve army of
War obsession with military expenditures is workers for rapidly shifting multinational
giving way to other means of social control. industries. Thus, in the 1990s we are
The ideology of population control is being witnessing an intensification of efforts at
refurbished, polished with a feminist and population control in both South and North.
environmentalist gloss, and marketed with
the latest in mass communication
techniques. Summarising a Pentagon study
Mechanisms in the South
of global demographic trends, Gregory
Foster of the US National Defense In the South the main mechanisms of
University writes: population control are the following:
Already the United States has embarked on Structural adjustment: Government
an era of constrained resources. It thus commitment to reduce population growth is
becomes more important than ever to do often a condition of structural adjustment
those things that will provide more bang for loans from the World Bank and the IMF.
every buck spent on national security ... This is most recently the case in India,
[Policymakers] must employ all the where government expenditure on
instruments of statecraft at their disposal population control is planned to increase,
(development assistance and population and international agencies are accelerating
planning every bit as much as new weapons their efforts in the wake of an IMF
systems).l agreement.2
Population control in the new world order 81

Targeting population assistance at the need for population control. This ranges
countries with the largest populations: The from simplistic computer graphics and
US Agency for International Development presentations to the confidential 'gray
(USAID) is planning to double its aid to 17 cover' reports of the World Bank.
so-called 'BIG countries' (India, Indonesia,
Brazil, etc.) in a move hailed as 'bringing a
demographic rationale back into the Mechanisms in the North
program'.3
Meanwhile, in the North, intensification
Rapid introduction of long-acting, takes these forms:
provider-dependent contraceptive technol-
ogies, such as Norplant and possibly the new Expensive and sophisticated lobbying
contraceptive vaccine, in health systems and propaganda efforts by population
which are ill-equipped to distribute them agencies, trying to attract increased aid-
safely or ethically. In addition to targeting allocations for population control. European
women and minimising user-control, these governments and parliamentarians have
technologies, unlike barrier methods, do become a new focus of these efforts.6
nothing to protect women from sexually European women's health activists report
transmitted diseases, notably ADDS. They that their governments' aid agencies are
perpetuate the notion that contraception is a under pressure to change their relatively
woman's responsibility, furthering the progressive stances on population to ones
neglect of male methods such as the condom more in keeping with the UNFPA and World
and vasectomy. Bank agenda.7

Renewed pressure on governments to Alliance-building between population


remove prescription requirements and agencies and mainstream environmental
dispense with basic medical standards for organisations, which accelerated in advance
hormonal contraceptives: For example, in a of UNCED in Rio in June 1992. 'Because of
letter to the International Planned its pervasive and detrimental impact on the
Parenthood Federation (IPPF), USAID global ecological systems, population
criticises 'medical barriers' to providing growth threatens to overwhelm any possible
hormonal contraceptives such as 'excessive gains made in improving living conditions,'
physical exams (e.g. pelvic and breast)' and reads a recent 'Priority Statement on
'holding the oral contraceptive "hostage" to Population' signed by many US population
other reproductive medical care (e.g. pap and environmental groups.8 Such messages,
smears and STD tests) ... With respect to broadcast through the media and local
contraindications,' the letter continues, 'we activist networks, fuel racist prejudices
prefer not to even use the term'... since it against Southern peoples and black com-
'may have very negative connotations and a munities in the North. Images of the
major inhibitory effect.'4 population explosion are back in vogue.
Dark-skinned babies are portrayed as
Mass marketing, both of contraceptive 'mouths to feed', and rarely as potentially
brands and neo-Malthusian messages, productive human beings.9
through social marketing programmes and
US financing in the South of popular Immigration restrictions: In the USA and
performers, radio and TV shows, and media Europe, immigrants are viewed as a threat to
networks which neatly converge with the the economy, to white dominance, and even
interests of pharmaceutical companies.5 to the environment. According to Paul and
Anne Ehrlich, authors of The Population
Continued data collection and analysis Explosion:
designed to persuade Southern officials of
82 Development for Health

The United States faces very serious and Population double-speak


complex problems with immigrants from
developing countries. The nation has First in the double-speak lexicon is the
traditionally said that it welcomed the concept of choice. The difficulty with this
'poor and downtrodden' of the world, but term is that opponents of abortion and
unhappily the 'poor and downtrodden' are 'artificial' contraception have made anyone
increasing their numbers by some 80 who supports access to them appear to be
million people a year. Many of these, of pro-choice. Thus, population agencies claim
course, would like to come to the United that they are expanding women's reprod-
States or other rich countries and acquire uctive choices by developing and promoting
the standard of living of the average new contraceptive technologies: the more
American (in the process greatly increasing technologies that are available, the logic
their use of Earth's resources and abuse of goes, the more choices for women.
its life-support systems).10 Perhaps the greatest master of this partic-
ular language is the Population Council,
The solution? Population control in the which developed Norplant and which is
South, immigration control in the North. now promoting its use in countries with
large top-down population-control bureau-
Coercive population control of poor cracies. With input from women's health
women, especially women of colour: In the activists, eloquent guidelines for Norplant
USA, while abortion rights are being providers have been drawn up regarding
seriously eroded, state legislatures are con- informed consent, respecting women's
sidering proposals to give cash incentives to request for removal on demand, and so on.
women on welfare to use Norplant; courts in Yet the fact is that such guidelines are
California and Texas have ordered women essentially meaningless in demographically
to accept Norplant as a condition of driven family-planning programmes where
probation. An editorial in the Philadelphia women's needs have never been adequately
Inquirer, a prominent US newspaper, respected. Examples abound of women
suggested that Norplant should be used as 'a being refused Norplant removal, as well as
tool to fight against black poverty' and being denied adequate information and
'reduce the underclass'.'' health back-up.12 Is it technocratic hubris,
The language in this editorial was so political naivety, disingenuousness, or a
extreme that the newspaper was ultimately combination of all three which makes
forced to apologise. Usually, of course, the population agencies so intent on promoting
language of population control is more Norplant in systems where 'choice' is last
subtle and seductive, a piece of Orwellian on the list of priorities, and population
doublespeak which plays on people's control is first?
genuine concerns about the status of women Interestingly, one of the new strategies is
and the preservation of the environment. On to involve women's groups and health
the positive side, this language may advocates in the introduction and
sometimes represent a genuine change in monitoring of Norplant and other new
thinking; on the negative side, it co-opts and technologies. Referring to a series of such
obscures. To avoid that pitfall, I believe that meetings, an activist writes that although
feminists and progressives must constantly they were ostensibly designed to open up a
expose the contradictions of population dialogue, their main purpose was 'to divine
doublespeak and clearly articulate our own
[women's] arguments, appropriate their
meanings so they cannot be turned against
language and finally exhaust them'.13
us.
Although dialogue can be useful,
women's groups must insist on their own
Population control in the new world order 83

terms as a precondition for participating. In Another key term in population double-


particular, these must include the right to speak is improving women's status. Even
make dissenting reports, to be published, the most die-hard Malthusians are for it,
unedited, in the official reports of the provided of course that it doesn't upset the
agencies concerned. global status quo. Female literacy, after all,
And then there is the larger question: is closely correlated with lower birth rates:
don't women's groups have more pressing educated women use family planning more
work to do than to monitor the introduction effectively.
of easily abused technologies in already While trumpeting their commitment to
abusive systems? Shouldn't the focus be on raising women's status, many of the same
changing the systems themselves? people who bring us population control are
Contraceptive vaccines, which immunise bringing us structural adjustment pro-
women against a hormone produced early in grammes, slashing health and education
pregnancy, are likely to prove even more budgets, laying off workers, raising food
medically and ethically problematic. prices, and occasionally casting a few moth-
Although one vaccine has been tested on eaten World Bank safety nets to catch the
only 180 women in India, it is being billed poorest of the poor. The result is disastrous
there as 'safe, devoid of any side effects and for the health of women and children. The
completely reversible'.14 The scientific solution? Family-planning programmes.
community knows very well that such Miraculously, family planning is some-
assertions are false. For instance, many how to lift women from their sorry status
questions still remain about the vaccine's without having to make meaningful social
long-term impact on the immune system and economic change. So, the argument
and menstrual cycle. There is also evidence runs, even more of the dwindling health
on film of women being denied information budget should be spent on it. And, in the
about the vaccine in clinical trials.15 words of the Population Crisis Committee,
Nevertheless, the vaccine is being prepared organisations such as USAID should take
for large-scale use. care not to 'diffuse or weaken' family
Meanwhile, the WHO Human Reprod- planning 'by shifting to a broad reproductive
uction Programme is testing its own contra- health or maternal and child health
ceptive vaccine. The chair person of a 1989 orientation...'.17
WHO symposium summarised the debate: Yet, despite their zeal to reduce birth
rates, the population controllers leave many
Foremost in my mind during these
of the determinants of high fertility in place:
discussions was our difficulty in assessing
the need for children as a source of labour
the urgency of the demographic crisis. To
and security, high infant mortality, limited
the extent that the impact of that crisis
economic opportunity for the poor. In the
increases, the need for more effective family
New World Order, even the saying 'Devel-
planning methods must increase. At the
opment is the best contraceptive' has an old-
very least, failure to develop something that
fashioned ring to it, rather like 'basic needs',
might provide a more effective technology
'equality', and 'human rights'.
would be to take a grave and unnecessary
risk.'6 There is yet another constellation of
double-speak terms, including the environ-
ment. Preserving the environment is the
What about the grave and unnecessary risks
latest ideological rationale for population
taken with women's health? Genuine
control, even though the major causes of
choice entails real power, not being on the
global environmental degradation lie else-
receiving end of a system designed to control
where, in inequitable economic systems,
your body as a means of controlling world
corporate agriculture and logging, military
population-growth.
84 Development foi Health

and industrial toxic wastes, and inappro- care' are a step forward. But for the poor,
priate technology. Why are the rich always there is not likely to be real quality of care
missing from the neo-Malthusian picture of until there is better quality of life.
the environment? Are they so invisible? In the end, blaming poverty and environ-
And then sustainability, a word so easily mental degradation on population growth
manipulated that in an article called 'Health obscures the real causes of the current global
in a sustainable ecosystem', Dr Maurice crisis: the concentration of resources
King can write in The Lancet that where economic, political, environmental in the
there is ^unsustainable population pressure hands of an ever more tightly linked inter-
on the environment, public-health systems national elite.
should rot use oral rehydration for the Two centuries ago, Thomas Malthus put
treatment of diarrhoea in babies from low- forward this analysis:
income families.18 Rather than indicting
That the principal and most permanent
this argument, the editorial observed that
cause of poverty has little or no direct
'Nothing is unthinkable'. The definition of
relation to forms of government, or the
sustainability must, in my view, be
unequal division of property; and that, as
expanded to include moral sustainability.
the rich do not in reality possess the power
Malthusian eco-fascism is morally un-
of finding employment and maintenance
sustainable, as are theories which claim that
for the poor, the poor cannot, in the nature
AIDS is a good thing, since it reduces
of things, possess the right to demand them;
population pressure on the environment.
are important truths flowing from the
Such views exceed the earth's carrying
principle of population.20
capacity for racism and injustice.
My final slippery term is consensus. This
In the New World Order, the essence of
is a favourite word of the United Nations
population control remains this simple
Fund for Population Activities, which is
political imperative.
proud of the way it has forged an
international 'consensus' around the need
for population programmes.19 But whose
consensus is it? I, for one, am not part of the Notes
grand UNFPA consensus. 1 Gregory D. Foster: 'Global demographic
Women and men need access to safe birth trends to the year 2010: implications for
control, including abortion. But when US security', Washington Quarterly,
family planning is designed and Spring 1989.
implemented as a tool of population control, 2 See, for example, 'USAID offers Rs. 800
it undermines health systems, targets Cr. to UP', Times of India, 15 February
women, fosters abuse, and perpetuates the 1992. On World Bank conditionality, see
'technical fix' mentality which has distorted Fred T. Sai and Lauren A. Chester: 'The
contraceptive research and development, role of the World Bank in shaping Third
and has led to the systematic neglect of World population policy', in G. Roberts,
barrier methods and male contraceptive ed.: Population Policy: Contemporary
methods, and a lack of concern for health Issues (New York, Praeger, 1990).
and safety. This is not to negate the need for 3 Tom Barron: 'New USAID population
contraceptive research. But priorities must strategy aimed at "BIG Countries",'
change, and women must have control over Family Planning World, Jan/Feb 1992.
the technological process before research 4 Letter from James Shelton, Chief,
truly expands reproductive 'choices'. Research Division, USAID Office of Pop-
Within family-planning programmes, ulation, and Cynthia Calla, Medical
efforts at reform by improving 'quality of Officer, Family Planning Services
Population control in the new world order 85

Division, to Carlos Huezo, IPPF Medical 15 This is shown in two excellent docu-
Director, 21 Aug 1991. Also see 'Paying mentaries: 'Something Like a War', a film
for family planning', Population Reports, on the Indian family-planning pro-
Series J, No. 39, November 1991. gramme by Deepa Dhanraj (D & N
5 See ibid, and 'Lights! Camera! Action!: Productions, 58 St Marks Road, Bangalore
Promoting family planning with TV, 560001) and a film about the vaccine,
video and film', Population Reports, made by German producer Ulrike Schaz
Series J, No. 38, December 1989. (Bleicherstr. 2,2 Hamburg 50, Germany).
6 See, for example, 'Europeans adopt 16Quoted in Judith Richter, 'Research on
population agenda', Population antifertility vaccines priority or
(UNFPA), Vol 18, No. 3, March 1992,. problem?', Vena Journal, Vol 3, no. 2,
7 Personal communications. November 1991.
8 Contact organisations: Zero Population 17Shanti R. Conly, J. Joseph Speidel and
Growth and Humane Society. Sharon Camp: US Population Assistance:
9 See, for example, Paul and Anne Ehrlich: Issues for the 1990s (Washington, DC:
The Population Explosion (New York, Population Crisis Committee, 1991).
Simon and Schuster, 1990). This book 18Maurice King: 'Health is a sustainable
calls Africa 'the dark continent' (p. 83). state', The Lancet, Volume 336, no. 8716,
lOIbid., p. 62. 15 September 1990.
11 'Poverty and Norplant: can contraception 19Nafis Sadik: 'The role of the United
reduce the underclass?', Philadelphia Nations from conflict to consensus' in
Inquirer, 13 September 1991. See Julia R. G. Roberts, ed.: Population Policy:
Scott: 'Norplant: Its Impact on Poor Contemporary Issues (New York,
Women and Women of Color', Public Praeger, 1990).
Policy/Education Office, National Black 20Thomas Malthus: An Essay on
Women's Health Project, for information Population, Volume II (New York: E.P.
on Norplant. The state of New Jersey has Dutton, 1914), p. 260.
also passed welfare 'reform' legislation
which denies benefits to children born to
women already receiving public
assistance.
The author
12See, for example, Sheila J. Ward et ah: Betsy Hartmann is the Director of the
'Service Delivery Systems and Quality of Population and Development Program at
Care in the Implementation of Norplant Hampshire College, Massachusetts, USA,
in Indonesia' (New York: Population and Co-ordinator of the Committee for
Council, February 1990). Women, Population, and the Environment.
13Personal communication. Her published works include Reproductive
14'Birth control vaccine for women Rights and Wrongs: The Global Politics of
developed', Planned Parenthood Bullet- Population Control and Contraceptive
in, Family Planning Association of India, Choice (New York, Harper Row, 1987;
Volume XXXIX, No. 5, November 1991. revised 1995, Boston: South End Press).
For a review of contraceptive vaccines, This article is based on a paper presented
see Angeline Faye Schrater: 'Contra- at the forum on Population Policies,
ceptive vaccines: promises and problems' Women's Health and Environment
in Helen Holmes, ed.: Issues in Women's Event, UNCED 92 Global Forum
Reproductive Technology I: An Anthol- in Rio de Janeiro, in 1992. It was first
ogy (New York: Garland, forthcoming in published in Development in Practice
1992). Also a forthcoming pamphlet by Volume 2, Number 3, in 1992.
Judith Richter.
86

Adjusting health care: the case of Nicaragua

Centro de Information y Servicios de Asesoria en Salud (CISAS)

We are approaching the end of the century, first five years, there were unprecedented
the date set in 1978 at Alma Ata for achiev- advances in the social sector. Between 1979
ing 'Health for All by the Year 2000'. and 1984, the spectacular increase in health
Undeniably there have been many advances coverage resulted in reductions in infant
since this goal was set. But there have also mortality rates, deaths from infectious
been enormous steps backwards. 'Health for gastro-intestinal and respiratory diseases,
All' seems farther away today than ever and immuno-preventable illnesses. There
before. The conditions in which the was also a drop in the number of child
majority of the world's population live have beggars and female prostitutes. So impress-
worsened. Structural Adjustment Pro- ive was this progress that Nicaragua's
grammes have had a dramatic impact in all UNDP index of 'low human development'
spheres, especially in health and education. was up-graded to one of 'medium human
And Nicaragua is no exception. development', even though economic
conditions showed far from similar
improvement.
Changing health policies in From 1984, the rate of social advances
Nicaragua slowed through what came to be called the
'survival period' caused by the Contra war,
The state of a nation's health is determined and problems were intensified by the
by macro-economic and socio-cultural economic adjustment and stabilisation pro-
factors, as well as by the provision and con- grammes begun in 1988. Investment in the
sumption of basic goods and services. health sector declined, leading to a gradual
Government policies, as well as levels of deterioration in the quality of services.
spending, are critical in establishing the The 1990s began with the election of a
health-care environment. government which embarked on an econ-
In the 1970s, it was widely held that omic programme to redirect resources
economic growth would lead to an towards the export sector, restricting overall
improvement in social conditions. The spending, especially in the public sector, and
Nicaraguan government's orientation at rolling back the State. All of this was done
that time was basically towards curative within IMF and World Bank guidelines.
health care. In the 1980s, the Sandinista While the programme succeeded in
government aimed to incorporate health stablising prices, its results in terms of
within an approach to social and economic production have been mediocre, with high
planning that was geared towards meeting social costs and an equally marked process
the needs of ordinary Nicaraguans. In its of exclusion. The per capita GDP dropped
Adjusting health care 87

from US$466 in 1989 to US$405 in 1992. level, in areas where the government has
Even if the pattern of wealth distribution insufficient presence, or no presence at all.
had remained the samewhich it did not So Nicaragua is virtually partitioned
more Nicaraguans would be living in between government and non-government
poverty, and the levels of poverty would be agencies, in which each defines its areas of
more acute. Unemployment rose to 54 per influence as it chooses, or in agreement with
cent of the economically active population, the Local Integral Care Systems created
while the per capita consumption of food by MINSA to encourage administrative
staples dropped by 25 per cent over the same decentralisation. This lack of coordination,
three-year period. together with the limited resources
The foundations were laid for a major available, seriously limits the chances of
deterioration in the nation's health: improving the health of most Nicaraguans.
subsidies for basic services and essential
products were eliminated; preventative
measures such as the 'complementary food' Health coverage: a return to the
programme were abandoned; and health past
services were generally reduced. As a result,
morbidity and mortality rates rose, in The 1970s were characterised by inadequate
particular among new-born babies and health services and by insufficient human,
children under the age of five. Maternal material, and financial resources. By 1977,
mortality rates rose, as did the number of only 42.5 per cent of the Nicaraguan
deaths due to respiratory and gastro- population had access to health care.
intestinal illnesses. By 1993 the UNDP re- The Sandinista government implem-
classified Nicaragua as 'low human develop- ented a PHC-oriented health programme,
ment', ranked 142 on the world scale. and in 1979 created the Unified Health
System. The principle was established that
health was a universal right, and health care
an obligation of the State. As a result, 83 per
Components of the health-care cent of the population enjoyed access to
sector in Nicaragua health services, and 186 new health units
Health care is covered by the public sector, were established throughout the country.
private business, and NGOs. But no real During the armed conflict of the mid-
coordination exists among them, nor are 1980s onwards, much health-care infra-
there recognised national standards of structure was destroyed, especially in the
service. The organisation and running of the rural areas. The hospital capacity deterior-
health-care sector thus depend on the ated, and by 1987 the ratio of beds per 1,000
various participants' particular interests, inhabitants dropped by ten per cent and
with the State handing over more of its has declined by a further nine per cent since
previous responsibilities to 'civil society'. then. Yet according to a 1993 MINSA
NGO participation, as well as the Report, fewer than 70 per cent of beds were
cooperation of multilateral and bilateral occupied, mainly due to the lack of supplies.
sources, was throughout the 1980s co- Access to health services today is limited
ordinated by the Ministry of Health not only by the reduction in public-sector
(MINSA). Now, however, most NGOs prefer supply, but also by the loss of free services,
to fund community initiatives directly, or since the government introduced a cost-
through grassroots organisations, thereby recovery policy. The increased supply of
avoiding government involvement. A private services serves only the better-off,
number of NGOs have emerged as an since the prices are beyond the pockets of
'alternative' response at the community most people. '
88 Development foi Health

Cuts in other social services also affect back. For example, immunisations for the
health. Government policy has been to major preventable diseases such as measles,
withdraw support for Child Development diphtheria, and tetanus dropped by 61 per
Centres (which in 1988 served some 38,000 cent, 23 per cent, and 44 per cent
children), so that coverage has fallen by 23 respectively between 1988 and 1994.
per cent since 1990. The number of child According to a survey by PROFAMILIA
street-workers has grown,- some observers [Salud Familial, Nicaragua 92-93), only 27
estimate that they constitute three per cent per cent of children are fully immunised
of the active work-force. UNICEF considers before they are one year old. Deaths due to
that as many as 700,000 Nicaraguan immuno-preventable diseases are rising, as
children are in especially difficult circum- are those caused by gastro-intestinal ill-
stances,- yet the government has defined no nesses. Malnutrition is now a major second-
policy to deal with the issue. ary cause of childhood death.
Finally, Nicaragua has seen a disturbing
increase in the number of deaths from
Charting the decline in health violent causes. Between 1988 and 1992,
crimes against individuals and drug-related
In the early 1980s, there were major gains in offences grew by 66 per cent and 96 per cent
the areas of infant and maternal mortality. respectively. The number of homicides
In 1972, for instance, the infant mortality went up by a massive 385 per cent.
rate was 122 per 1,000 live births a rate Unemployment and alcohol are, according
which had dropped by 40 per cent ten years to a police report on the subject, common
later. Maternal mortality also declined by denominators.
over one third over the same period.
With the problems associated with the
'survival period', fewer health professionals
Paying for health, and paying for
were employed by the State, and larger
numbers of children were not covered by
sickness
immunisation programmes. Increased In the early years of the Sandinista govern-
poverty and hardship, and the widespread ment, national spending on health (both
lack of access to safe drinking water, leave current spending and investment) steadily
people more vulnerable to illness. increased; though, as we saw above, it
But according to MINSA's records, declined from the mid-1980s. This down-
maternal mortality has soared since then. ward trend has continued: per capita
Today, one in every 66 women of child- spending on health fell from US$63 in 1988
bearing age dies due to complications to US$44 in 1992.
related to pregnancy or childbirth. For rich According to a 1993 World Bank diag-
countries, the figure is one in every 10,000. nosis, most of Nicaragua's existing medical
Infant mortality has also begun to rise, and equipment was already at the end of its use-
in some districts stands at 138 per 1,000 live ful life, and almost half was unreliable or out
births among illiterate mothers: six times of order. Almost all hospitals required major
higher than the index among mothers who repairs, and four needed to be replaced.
have completed primary, secondary, or In Nicaragua, the 'enabling State' is a
further education. Given that illiteracy has cosmetic term which conceals the govern-
risen since 1989, the likely consequences ment's abrogation of its responsibilities for
are all too obvious. health. The population has been abandoned
Nicaraguans are ever less likely to seek to its fate. Private spending has grown,
medical or dental treatment, and prevent- mainly in out-patient care and, of course,
ative health programmes have also been cut mainly in the capital city. It does not reach
Adjusting health care 89

low-income groups, and it does not serve the drafting our countries' social and economic
needs of anyone unable to travel to policies so that sustainable human develop-
Managua. ment is genuinely promoted.
NGO spending has increased by 48 per The Alma Ata recommendations should
cent since 1988. But while this is a be taken up again. These include the
significant trend, the amount is incorporation of health within an integral,
insignificant in terms of the cost of multi-disciplinary, and multi-sectoral
maintaining national health-care provision. approach to social planning. For this to
happen, more of us need to have a clear and
comprehensive picture of the situation, so
Putting health into perspective that we can build this into our demands and
proposals. Above all, we need to ensure that
What we have shown is not a pretty picture. people have the chance to express their
The panorama seems grim. According to views, and fight for these to be taken into
some, Nicaragua has already reached rock- account in the agreements, policies, and
bottom: things can only improve. While the plans both of governments and of inter-
situation is so bad that it is hard to imagine national financial institutions.
it getting any worse, we cannot afford to
assume that things will get better. If we do
not take concrete steps to counteract the
effects of Structural Adjustment Pro- Note
grammes in eroding health-care provision, This article is adapted from La salud y los
the situation will continue to deteriorate. ajustes estructurales en Nicaragua (avail-
We cannot talk about sustainable social able in English as Health and Structural
and human development without there also Adjustment in Nicaragua), published in
being a commitment backed up with February 1995 by the Centro de Informaci6n
action to change the structures that y Servicios de Asesoria en Salud (CISAS) for
promote and perpetuate inequity and the World Summit on Social Development.
injustice, and unless health care is designed Statistics are taken from official
to be accessible to every citizen. Both government documents, unless other
governments and organised civil society sources are cited.
have a responsibility to meet these
challenges. Human development and
economic growth cannot be seen as separ-
ate from each other. Access to basic
The author
services, among them health, is a funda- CISAS is a Nicaraguan NGO dedicated to
mental right of all people. grassroots education and social communic-
While the unjust policies and structures ation about health.
at an international level are very important The article synthesises research by Dr
obstacles to achieving social and economic Edmundo Sanchez of the Centro de Investig-
development, it is not enough merely to aciones y Estudios de la Salud of the Nicar-
reform them. We also have to make radical aguan School of Public Health. It was first
changes within our own countries to assure published in Development in Practice
the full participation of all members of our Volume 5, Number 4, in 1995.
societies, and their just and equitable access
to resources and services.
A major challenge facing civil society in
general in particular movements repres-
enting ordinary people is to participate in
90

Evaluating HIV/AIDS programmes


Hilary Hughes

What is a successful HIV/AIDS interven- already knew what helps to change


tion? This may sound like the million-dollar behaviour such as avoiding unwanted
question in AIDS prevention, but it need not pregnancy or stopping smoking and what
be. Answers can be found, if we are clear does not. Later, those working in HIV/AIDS-
who is asking the question, and why. specific programmes were to learn many of
First, we must define our objectives. the same lessons, but only after valuable
What can we realistically expect any time had already been lost.
HIV/AIDS intervention to achieve? Most We know that information alone is
AIDS-control programmes share the same insufficient to change behaviour. Informa-
fundamental aim: to reduce the spread of tion directed from outside through leaflets,
HTV through promotion of safer sexual talks, or mass media and marketing cam-
behaviour. This is a long-term objective, paigns towards individual members of the
requiring deep-rooted social change. public or target groups is not enough for
Evaluating the success of projects in the them to act on it. People are most likely to
short term by looking at longer-term change when those around them are
indications such as sustained changes in changing. In the case of sexual behaviour,
sexual behaviour can be demoralising and they change because their sexual partners
misleading: demoralising, because to expect are changing: it does, after all, take at least
that long-term goals can immediately be two to have safer sex! Encouragement of
achieved will often lead to a hopeless sense sustained, inter-personal communication
of failure; misleading, because those and 'peer' pressure are, therefore,
changes which can be observed cannot be fundamental.
attributed to any particular project or We could take as an example the way in
activity, since behaviours are affected by a which an existing community-based
range of external factors, from migration to primary health-care (PHC) clinic, set up by a
mass media. Residents' Association in Rocinha, Rio de
Janeiro, integrated AIDS-prevention work
into its activities. This local health post was
already providing medical care to over 5,000
The lessons so far
households, as well as promoting a
Despite difficulties in evaluating results in participatory response to common health
the short term, we have learnt important problems such as scabies and measles. The
lessons about successful promotion of safer work is inter-sectoral and inter-disciplinary,
sex. Before AIDS became a major public- involving residents, local and national
health concern, health-education workers media, and local and national government.
Evaluating HIV/AIDS programmes 91

Four years after diagnosing its first AIDS lack of water. Within this context, there are
patient in 1987, this same PHC programme always some individuals who have influ-
had set up and trained an extensive network ence within a group. This may be the local
of volunteer AIDS counsellors/educators in gang leader of street youth in Rio de Janeiro,
the community, as well as a system of free, or a national leader of the Brazilian Move-
targeted distribution of condoms, monit- ment of Street Boys and Girls, working to
oring their use through the inter-personal defend the civil rights of all young people
contact of the AIDS educators. The project living on the streets. Among migrant
has improved medical assistance to those workers, it may be a labour leader, or a leader
with HIV disease, improved relations with of an ethnic minority which forms part of
local State HIV-testing services, and the migrant labour force. These people can
established qualitative and quantitative use their position to integrate the issue of
monitoring and evaluation of all programme sexual health within their everyday
activities. community-development work. In this
Mass media and public educational case, the issue is to encourage more open
campaigns on AIDS prevention were also discussion on the topic of sexual pleasure
launched, including local radio pro- and disease prevention.
grammes, a video production featuring The success of any AIDS programme is
interviews with residents on their views crucially related to the level of organisation
about AIDS, a school play, and a popular already in existence before work on AIDS
dance [lambada). This illustrates ways of commences. The degree to which people at
enhancing peer pressure and inter-personal risk are already organised determines the
communication: people are more likely to effectiveness of their channels for com-
act on the information they receive in one munication and action. For example, the
sphere if the same messages are reinforced success of the Rocinha AIDS programme is
through other channels in their lives, such largely due to the pre-existence of the health
as radio, film, and discos. post already set up and run by the local
The success of this programme is largely Residents' Association.
due to the pre-existence of the health post The opposite is also true: the more
and its commitment to encouraging partic- vulnerable, isolated, and marginalised
ipatory peer education in the community, as people are, the less likely it is that they will
well as encouraging an integrated, inter- be able to change their behaviour and act on
sectoral response, involving mass media and the knowledge that they are at risk of HIV.
local government. This necessarily means that the political
How does an HIV/AIDS intervention organisation of vulnerable people to act
begin this process? We must first find a confidently in their own interests and to
'point of entry' in any particular group or articulate their concerns must form the
community at risk. This means that we broader objectives of any AIDS intervention.
need to find out how to make AIDS, or any Such objectives must, therefore, be taken
other sexual-health issue, relevant. To into account when evaluating the success of
persuade people that HIV/AIDS is any particular project.
important, the topic must be addressed in
the context of those issues which are of
more immediate concern: to a street child in
Success in whose eyes?
Brazil, this is surviving daily violence; to a
woman selling sex in a bar in Nairobi, it may How can we evaluate a project whose wider
be feeding her children,- to a migrant objectives include empowerment and
agricultural worker on the US/Mexican leadership development? Take, for example,
border, it may be poverty, pesticides, and a project focusing on sex-workers, or
92 Development for Health

prostitutes. The initial objective, as agreed Unfortunately, indicators are often


by the funders, is to set up a centre focusing selected not because they are the most
on safer-sex counselling and free distribu- appropriate, but because they are the easiest
tion of condoms. Attendance at the centre is to measure; for example, tracking the
at first minimal. The women's more number of condoms distributed, as opposed
immediate concerns include fear of violent to assessing the increased likelihood that
and abusive clients, many of them frequent these will, or can, be used for their intended
offenders. As the centre becomes a meeting purpose. Indicators should be creatively set,
place for sex-workers, discussion leads to using both qualitative and quantitative data
action,- and the women develop and up-date as appropriate. For example, a quantitative
a descriptive database on dangerous clients, evaluation of a project working with
known as the 'Ugly Mugs' file. Six months adolescents in Mexico, based on a statistical
later, a survey reveals that most women analysis of responses to a written
come to the centre primarily to pick up the questionnaire, seemed to indicate that
latest 'Ugly Mugs' information, rather than educational work on AIDS had caused more
the condoms. In the eyes of the sex-workers, adolescents to believe that contraceptives
this project is a 'success'. The women feel were difficult to obtain. Further qualitative
more confident not only about avoiding investigation (focus-group interviews)
dangerous clients, but also about collect- revealed that, as a result of the educational
ively demanding 'No condoms no sex'. programme, more adolescents had
The funders, however, are more keen to attempted to buy condoms a positive
ensure that their funds are spent specifically outcome but in doing so had discovered
on promoting condoms, rather than on a that many chemists did not stock them a
'social centre' for sex-workers. broader social problem which the
Given the complex factors which programme would have to find ways of
influence sexual behaviour, a project may addressing.
change its short-term objectives and/or Although there is no single way to
strategies, still with the same longer-term evaluate 'success', we can develop better
goals in mind. This is true of many health- ways of monitoring our achievements and
related initiatives, which begin with failures, on both an individual and a
specific aims and are then forced to confront collective basis:
far broader social issues. Where funders and
More effective information-exchange on
project workers begin to differ in their
the results of simple approaches to project-
proposed objectives, they will also differ in
evaluation will help similar projects to
the evaluation indicators chosen.
improve current activities, and learn from
past mistakes so long as realistic
objectives are set in the first place. Stated
Indicating social change objectives and indicators should broadly
reflect key aspects of the project's social and
One answer to this problem is to select
political context. Questions to ask in a
indicators, from the start, which reflect the
evaluation are then surprisingly simple: are
broader social issues that any HIV/AIDS
the stated aims and objectives being met?
project can expect to confront; and which
How is this being achieved? Simple research
are flexible enough to reflect the changing
techniques include comparative studies of a
reality of the project. For example, in the
group of people involved in any activity and
sex-worker project cited above, this would
a similar group which is not; and
entail finding ways to measure the women's
questionnaire surveys on the effect of
increased confidence to act collectively in
project activities on participants.
their own interest.
Evaluating HIV/AIDS programmes 93

Small-scale research into current sexual The author


practices, and monitoring changes, can be
used to inform project activities (although Hilary Hughes de Rodriguez, Reproductive
this cannot be used as a measure of an Health Adviser for GTZ, worked from 1987
individual project's success). For example, to 1992 as the AIDS Programme Coord-
community educators in Zambia promoting inator for AHRTAG, and was Editor of the
marital fidelity have used local Chief's international newsletter AIDS Action. She
Council records of assault cases as an currently works in Zimbabwe.
indicator of the incidence of sex outside An abbreviated version of this article
marriage, since 'most assault cases are the appeared in 1992 in the magazine AIDS in
result of one man sleeping with another the World. This version was first published
man's wife'. An apparent decrease in these in Development in Practice Volume 3,
cases has encouraged continued promotion Number 1, in 1993.
of marital fidelity as one approach to
reducing high-risk behaviour.

Improved communication between site-


specific projects and larger research pro-
grammes can help us to better relate the
aims and objectives of small-scale projects
to our collective, longer-term goals, i.e.
sustained behavioural change and reduced
spread of HIV. For example, large epidem-
iological and behavioural research prog-
rammes should ensure that all sexual health
projects operating in the areas under
investigation are informed of the results and
of their implications.

Many projects currently operate within a


two-three year funding cycle. Projects
should be encouraged to operate within
more appropriate time-frames, given the
longer-term nature of the ultimate goals.

In conclusion, there is one crucial lesson


that we do not have time to re-learn.
Community workers around the world
recognise that health promotion requires
deep-rooted social change. Sexual health is
no different. In measuring the success of an
HIV/AIDS intervention, therefore, one of
the most appropriate indicators will be
people's level of participation in this broader
struggle for social change.
94

Widows' and orphans' property disputes:


the impact of AIDS in Rakai District, Uganda

Chris Roys

llntroduction some cases, they have even evicted the


woman and her children from the house, and
The problems of HIV/AIDS in Uganda, chased them from the land.
especially in the Rakai District, have been The question of women's lack of right
well documented.1 A survey in Rakai in either to own or to inherit property has
1989 put the number of orphans at over become a focal issue for women's empower-
25,000. 2The 1991 population census puts ment and for development throughout
the number at 44;000.3 Africa.4 However, AIDS has brought mortal-
The Child Social Care Project (CSCP) in ity on an unprecedented scale, pre-
Rakai is addressing one of the social con- dominantly affecting those from 15 to 45
sequences of the AIDS pandemic: the years, who tend to have dependent children.
property rights of widows and orphans In some trading centres in Rakai, infection
children under 18 years who have lost one or rates are said to be as high as 37 per cent.5
both parents. In partnership with the Thus many widows are also infected with
Department of Probation and Social Welfare HTV. So, just at the time when they are least
in the Government of Uganda and Save the able to become economically independent,
Children Fund (UK), the CSCP aims to when they most need access to health care, a
develop the role of the Department in good diet and so on, they are denied it. Their
response to the enormous social problems children, who will probably be doubly
arising from AIDS. Social workers and orphaned, are likely to become homeless,
volunteers throughout the district are landless, and uneducated, in a context
assisted to develop a community-based where 90 per cent of the population depends
approach (as opposed to their traditional upon subsistence agriculture.
case-work role), and to coordinate services
There are three main interacting
for vulnerable children.
mechanisms which regulate inheritance in
Rakai: wills, customary law, and statutory
law.
Widows' and orphans' property
disputes
Wills
Since April 1991, hundreds of disputes over These are a fairly modern idea, to which
property have been referred to the CSCP there is still considerable resistance. Firstly,
staff. Usually, a father and husband has died illiteracy is high, especially among women,
from AIDS, and other relatives have taken and written documents are an alien concept
property from the widow(s) and orphans. In over which illiterate people have no control.
Widows' and orphans' property disputes 95

Many people are fearful of legal institutions countless members are unborn'. When a
and avoid contact with the law wherever woman dies, her property (if any) may pass
possible. A written will is seen as a legal across the generational line, for example to a
document and, therefore, to be avoided. sister, but not to her children, as they belong
Even more importantly, many fear that by to the male line.
making a will they will bring about their In the past, the clan system was relatively
own death. strong and able to regulate inheritance
However, wills are written and do play a satisfactorily. However, the processes of
part in inheritance. A problem is that, in the social, economic, and political change have
face of illness, people with HIV infection reduced the importance of the clan a
sometimes assume that their death is decline that has been accentuated by the
imminent and make a will. Traditionally, impact of ADDS.
the will is made in secret and given to one Everyone in the community has been
person to keep. However, patients often affected by the high rates of mortality,
recover from the opportunistic infections sickness, and bereavement. There is nobody
associated with the disease, and can survive who has not lost a close family member. For
for many years before dying. Thus, they may some, this has led to a sense of fatalism: 'We
make a will each time they think they may are all infected and are going to die'. While
die. Thus there may be several wills held by Some have taken comfort in religion, others
different people, and conflict about which is have adopted the attitude of 'grab what you
the right one. In addition, a person's last can while you can'. Thus the authority of a
verbal requests are supposed to be honoured, clan which looks backwards and forwards
which introduces a further complicating over generations is undermined.
factor. The people most directly affected by AIDS
are young adults, including the more
educated and wealthy, who would not
Customary law otherwise have been expected to die. This
Under customary law and practice, issues of too puts a strain on the clan system, as the
inheritance and the disposal of property people with greatest influence may already
(including widows and orphans, who are have died; and the eldest son and heir is
part of the estate) were decided by the family often a young boy, rather than a mature
and clan members at the last funeral rites, man. The deceased may also have many
which would take place up to a year after the dependants, whom other clan members will
burial. struggle to support. Customs of polygyny
An heir would be appointed, usually the may complicate matters. When a man dies,
eldest son, or the eldest male relative in the he may leave several widows, each with
male line. In the case of a minor, the clan orphaned children. In some cases, all the
would appoint a caretaker until he reached wives know each other and are aware of
an appropriate level of maturity to take on their relative status. In others, the fact that a
his responsibilities. The heir becomes the man had several wives may emerge only at
head of the family, and as well as being the burial. Thus, the relatives of different
responsible for both the assets and liabilities widows may compete to inherit property.
of the deceased, he acts as the guardian of The sheer scale of the problem places a
widows and orphans. In particular, the heir further burden on the families and the clan.
is given the residential house of the deceased Burials, once an unusual occurrence, are
and is not supposed to sell any land he has now an everyday event. Last funeral rites are
inherited, because (according to a Buganda now being combined with burials, in order
saying) 'land belongs to a vast family, of to save time and money.
which many are dead, few are living, and-
96 Development for Health

Statutory law women and children losing their property,


housing, and land. On referral, the social
Where customary law fails, statutory law
worker usually calls the complainant to the
can be invoked.6 This distributes property
office to hear her side of the story, counsel
thus: 15 per cent to the widow(s), 75 per cent
her, and assess how to proceed. The next
to the children, 9 per cent to parents and
step would be to visit the site of the dispute
brothers, and one per cent to the heir.
and to seek audience with the other party.
However, while the widow(s) and orphaned
The social worker may be able to mediate at
children have a right to stay in the house and
this stage. However, even if agreement is
land, this property still belongs to the heir.
reached, it is important to involve other
Nor is the widow the guardian of her
community members, so that the
children, responsibility for whom also falls
agreement is known, accepted, and upheld
to the heir.
in the future.
The social worker's primary concern is to
see that children are provided for
The Child Social Care Project adequately. Usually, this means acting as an
The CSCP has developed a long-term, advocate on behalf of the children and the
preventative approach to these problems, mother. However, the social worker must
trying to change people's attitudes, beliefs, also understand what will be acceptable to
and behaviour. There are three elements: other members of the community, so that
the widow and orphans will be supported
Community sensitisation: Conducting and accepted by them.
seminars with local officials in the district, Traditionally, the clan was important in
notably chiefs (who are civil servants) and settling inheritance claims, with its leader
Resistance Councils (who are members of chosen for his wisdom and experience.
elected councils from village through to However, this institution has been
district), to inform them about the laws of weakened, and it is now less effective and
succession, and about women's and cohesive. The CSCP workers aim to
children's rights. strengthen the role of the clan. A meeting
Training: Parish-level volunteers, known will be chaired by the clan leader, at which
as child' advocates, are trained in issues the social worker explains his/her role, talks
concerning children's rights and protection, about children's rights, and reminds the clan
including the property of widows and of its responsibilities. Both sides to the
orphans. They can identify problems at an dispute are then heard, and opinions sought
early stage and prevent them from getting out from members. The social worker helps the
of hand. Other NGOs have also trained para- meeting to identify various options and
legals to assist in this process. come to an agreement, which is then
forwarded to the Village Resistance
Writing wills: CSCP staff, social workers, Council.
and volunteers encourage people to make The comprehensive Resistance Council
wills, especially if they are already sick. This (RC) system was introduced by the Ugandan
involves counselling to overcome the fears government in 1986, incorporating all
and resistance already mentioned, as well as adults in the country through a series of
help in writing the actual document. Local interlinked committee structures. Where
leaders are also involved in this process, to the clan is unable to resolve the dispute, or
avoid the conflicts earlier described. where its leaders have a personal interest in
the case, the social workers involve the
Many cases referred to the CSCP have village RC. Again, the social worker will
required an immediate response, to prevent remind the Council about children's rights
Widows' and orphans' property disputes 97

and inheritance law, and help the meeting to She had to buy food, because her banana
come to an agreed solution. plantation was damaged by cattle belonging
Recourse to statutory law may also be to the heir.
sought through the courts, if the clan or the
The animals allocated to her and her
village RC cannot resolve the dispute. How-
children had no salt or drugs.
ever, even where magistrates make a ruling,
the CSCP persuades them to attend village The hut she lived in was on the verge of
meetings to explain their judgements. collapsing.
She lacked essential domestic items, such
as soap, salt, and paraffin.
Case study
A social worker was called to attend to the She therefore decided to go to her parents, so
case of a widow with three children aged 7 that she could get assistance for her
years, 3 years, and 7 months respectively. children. She had called the clan of her late
She wanted to return to her father's home, husband to listen to her problems, but
where she knew she would be assisted, nothing positive had been done. She had
together with her children and cattle. often contacted the brothers and sisters of
However, the heir refused to let her go. The her late husband, but was referred to the
Magistrate, clan members, relatives, and heir, who was working far away from home.
RCs in the area were invited to discuss to the So she called her relatives and asked them
case. to decide what should be done next. Her
According to the clan leader, the husband father decided that, since she was not
had had seven wives and 20 children. Before receiving any assistance either from the heir
he died, he had already allocated land to each or from the clan, and her problems were not
of his wives. Other property was allocated to being addressed, he would obtain a permit to
the children and widows by the clan after his move the cattle belonging to his daughter
death. This included cattle, some corrugated and take her to his home.
iron sheets, and barbed wire. It had also been When the 24-year-old heir heard of the
decided that the deceased's motorcycle move, he immediately took the matter to
would be sold, and the proceeds distributed court, and the Magistrate made an injunc-
equally among the children. tion order stopping the movement of the
However, this decision was later changed animals until the matter was heard.
by some individuals without consulting the The widow also claimed that she had been
head of the clan. They allowed the heir to given various items, including a room at a
take the motorcycle, because he had not trading centre and some cattle for herself
been allocated anything of his late father's and her children, as well as the land already
property. allocated to her by her late husband. Some of
The 28-year old widow was the junior wife these had been taken by the heir.
of the deceased. Since her husband died, she The heir claimed that the widow had
had encountered the following problems: obtained a permit issued by the veterinary
department to move the animals to her
She was no longer able to send her parents' home, without his knowledge, and
daughter to school, because she could not that he should have been informed first. So
afford the fees. he took the matter to court, and the move-
She had no-one to look after the cattle,- she ment of the animals was blocked. He stated
was responsible (as the junior wife) for that the widow was the cause of her own
attending to all the cattle before her husband problems, since she had suggested that
everyone should look after their own cattle.
died.
98 Development for Health

He also complained that, unlike other together with her three children and the
children, he was not given anything during animals, could go to her parents' home,
the distribution of property, yet he was also where she could be given assistance.
a son of the deceased. Support would also be given by other
Having heard from both sides, the CSCP paternal uncles who were present at both
team opened the meeting to other clan meetings. The children were free to visit
members, some of whose views are reflected their clan (their father's relatives), and this
below. should be encouraged.
This case shows how complicated such
The elder sister of the deceased said that
issues are, with many people involved. It
the widow should go to her parents' home
also indicates the amount of time that has to
with all her property, including the children.
be devoted to the resolution of such con-
A brother of the deceased said that the heir flicts. Two main issues should be emphas-
could take responsibility for supporting the ised.
widow, and then there would be no com-
plaint. He said that the widow should go to
her parents' home with the children, but Gender
leave the animals and any other property. The patriarchal nature of the society in
which these conflicts take place is clearly
Another sister of the deceased said that the major issue. The clan system is patri-
the meeting should decide, because she was lineal, and thus under customary law
at a loss to know what to do. women cannot inherit property. This is
The heir said that the widow could go because a widow may go back to her father's
with the child of 7 months, but should leave clan, taking any property with her, which
behind the other two children, together with would then be lost to the deceased's clan.
their animals. The social workers asked him This matter is related to the custom in some
who should care for the children, but he was areas of widow inheritance.7
unable to answer, except to say that he had The woman has no entitlement to prop-
no home of his own and was not married. erty not even to her children, since they
too belong to the clan, and the heir becomes
The Chairman of the RC suggested that an their guardian. Male children will take up
administrator of the deceased's estate their position in the clan in due course,
should be appointed, with powers over while girls will be 'sold off for bride price.
everything, instead of investing powers in
Polygyny also discriminates against
the heir, as was customary. He noted that women and increases their vulnerability
some appointed heirs may be too young to and that of their children, especially in
manage family matters. relation to AIDS. In the case described, the
deceased had seven wives. In some areas,
By now, the discussion had taken most of child marriage is common, so a junior wife
the day, without coming to a solution. The may be a teenager, while her husband is a
social worker suggested that time be given man in his fifties. Modern statutory law also
to enable both parties to study the whole discriminates against women, specifying
matter again, with a decision to be taken in that 'a male shall be preferred to a female'.
ten days' time.
The empowerment of women is the long-
On the agreed day the team went to the term solution to problems such as these, and
village, together with the Magistrate, to in small ways the CSCP hopes to contribute
meet with the parents of the widow, the clan to it. Clan and RC meetings tend to be
of the deceased, the heir, and other relatives, dominated by men, and the social workers
as well as neighbours and members of the who facilitate them are very conscious of
general public. It was agreed that the widow,
Widows' and orphans' property disputes 99

the need to ensure that women attend such Notes


meetings, and actively seek their opinions.
However, although the female social I am grateful to the project staff and
workers provide a role model, it is hard to get especially Alex Bagarukayo, Gertrude
women to express themselves freely in Wanyana, and James Ssekinwanuuka for
public. One possible solution is to hold their contributions to this article. Any
some women-only meetings beforehand, omissions and errors, however, are my
although this can make the men suspicious responsibility.
and antagonistic. 1 A. Barnett and P. Blakie (1990): Commun-
ity Coping Mechanisms in the Face of
Exceptional Demographic Change,
Legal reform London: ODA; A. Dunn (1992): 'The
Changes in the law are needed, to allow Social Consequences of HIV/AIDS in
women to inherit on an equal basis with Uganda', Overseas Department Working
men. However, legal changes on their own Paper No. 2, London: Save the Children
will achieve nothing. The law in Uganda, for Fund UK.
example, prohibits sexual intercourse with a 2 S. Hunter and A. Dunn (1991): Enumer-
girl under the age of 18 years, yet 'defile- ation and Needs Assessment of Orphans
ment' is common, and the law-enforcement in Uganda, London: Save the Children
agencies are reluctant to take any action. Fund UK.
The law has to be acceptable to people, 3 Population and Housing Census, Govern-
otherwise they will disregard it. A process of ment of Uganda, 1991.
education and sensitisation is needed to 4 D.M. Martin and F.O Hashi (1992):
change attitudes. People must be involved Women in Development: The Legal
in decision-making: thus, the law must be Issues in Sub-Saharan Africa Today,
taken to the people, and not simply imposed Washington: World Bank.
from above. 5 AIDS Control Programme, Rakai Report,
Uganda, 1993.
6 Succession Act as amended by the
Conclusion Succession (Amendment) Decree 1972.
7 B. Olbwo-Freers and T. Barton (1993):
The CSCP has had considerable success in Studies in Cultural Diversity, New
settling individual disputes. More York/Geneva: UNICEF.
important, we have also had some success in
enabling communities to deal appropriately
with these conflicts without recourse to
'experts'. The author
Promoting the empowerment of women Chris Roys has worked for Save the Children
is important, but this phrase has become so in the UK and in Uganda, where he is a
overused that it is in danger of becoming social-work adviser in Rakai District. He is a
meaningless. A vital aspect of empower- qualified social worker and has a particular
ment is economic independence. In the interest in child abuse and child protection,
CSCP we are involved in helping women to the impact of HIV/AIDS on children, and
claim the right to own property, land, and exploring methods of talking to and
housing, as well as to care for their children. listening to children.
While this will not in itself empower them, This article was first published in
it will at least help women to achieve some Development in Practice, Volume 5,
degree of economic power to provide for Number4,inl995.
themselves and for their children.
100

Annotated bibliography

Of the vast literature on health-related matters, we offer here a selective listing of recent and
classic English-language publications that focus on the relationships between development
and the politics of health. Some of the most penetrating contemporary work in this field has
been undertaken by Southern feminist networks and women health professionals, in the
context of women's health and rights, much of this in preparation for thel 994 International
Conference on Population and Development. Their insights into exclusion, and the social
institutions through which it is maintained, are of wider application in the field of health
and development and hence are highlighted here. A sample of journals that take a multi-
disciplinary approach to health matters is included, together with international health
organisations and health-related networks.
Like the Reader itself, the bibliography is aimed at practitioners and academics with an
interest in exploring the links between development and health. It does not cover detailed
aspects of health care, nor does it include material of a highly specialised medical nature.
This Annotated Bibliography was compiled by Eleanor Hill, Deborah Eade, and Caroline
Knowles (Editor and Reviews Editor respectively of Development in Practice), with
assistance from Mohga Kamal Smith (Oxfam Health Policy Adviser).

Ehtisham Ahmad, Jean Dreze, John Hills, factual information regarding the disease
Amartya Sen (eds): Social Security in and its transmission as well as descriptions
Developing Countries of a wide variety of initiatives and projects to
Oxford: Oxford University Press, 1991 combat HIV. It highlights many issues
A broad-ranging collection of authoritative which would otherwise remain hidden
papers gathered under the auspices of the without its strong gender analysis.
United Nations University, focusing on
social security including employment British Medical Association: Medicine
generation, provisioning of health care and Betrayed: The Participation of Doctors in
education, land reform, food subsidies, and Human Rights Abuses
social insurance and how State policies London: Zed Books, 1992
and public action can act to reduce human An authoritative and informative account of
deprivation and eliminate vulnerability. the responsibility of physicians to protect
human rights, this provides a thoughtful
Marge Berer with Sunanda Ray: Women ethical commentary, an overview of
and HIV/AIDS: An International Resource international law relating to torture and
Book medical experimentation, and practical
London: Pandora Press, 1993 guidance for medical practitioners and
An excellent overview of the issues relating policy-makers alike. The context in which
to HIV/AIDS, covering all the necessary doctors may commit gross violations of
Annotated bibliography 101

human rights is itself one that is often effects on women of past and present
conditioned by fear, ignorance, or extreme fertility-management policies, the authors
coercion. The Working Party which argue for the indivisibility of health and
prepared this book addresses controversy rights. They identify the challenges to be
and dilemmas head-on. Some recommend- tackled by women in the South, and suggest
ations are provocative and will stimulate strategies for political action by the
productive debate. international women's movement.

Peter Coleridge: Disability, Liberation, and Robert Desjarlais, Leon Eisenberg, Byron
Development Godd, and Arthur Kleinman: World Mental
Oxford: Oxfam (UK and Ireland), 1993 Health: Problems, Priorities, and Responses
Taking as his point of departure the in Low-income Countries
systematic oppression and marginalisation Oxford: Oxford University Press, 1995
of disabled people, the author examines the Based on the collaborative work of over 120
social attitudes that give rise to such experts worldwide, this book represents the
exclusion, and looks at ways in which it can first systematic attempt to survey the
be overcome. The book thus offers an suffering caused by mental-health
insight into the processes of liberation and problems. It brings together information on
empowerment that are the touchstone of mental illness and behaviour that
development. influences health and potential for human
development, and on the promotion of
Rebecca J. Cook: Human Rights in Relation mental health as defined by the World
to Women's Health: The Promotion and Health Organisation that mental health
Protection of Women's Health through is not simply the absence of detectable
International Human Rights Law disease, but a state of well-being in which
Geneva: WHO, 1993 the individual can fulfil his or her full
This document examines the relevance of potential. Arguing that there are diverse
international human rights to the consequences of mental-health problems,
promotion and protection of women's and political, social and cultural forces
health, and provides a framework for future which bear on them, the book provides
analysis and for collaboration among examples, rather than bare statistics, to
organisations concerned with these issues. describe global patterns of problems and
The document explains the international, solutions. It shows how people in different
regional, and domestic mechanisms levels settings deal with them and identifies
that are available for holding States opportunities for developing more
accountable for their compliance with appropriate interventions. It concludes with
human-rights treaty obligations concerning an Agenda for Action and an Agenda for
women's health. Research.

Sonia Correa with Rebecca Reichmann: Ruth Dixon-Mueller: Population Policy and
Population and Reproductive Rights: Women's Rights: Transforming
Feminist Perspectives from the South Reproductive Choice
London: Zed Books in association with Westport, Connecticut: Praeger, 1993
DAWN/New Delhi: Kali for Women, 1994 The author's thesis is that the exercise of
From a Southern feminist perspective, the women's reproductive rights depends
authors consider conventional debates on fundamentally on the exercise of their rights
population and examine the inter-linking of in other spheres. Population-control
economic processes, demographic policies and programmes would probably be
dynamics, and women's lives. Analysing the unnecessary if women enjoyed their basic
102 Development foi Health

economic, political, and social rights and different non-government agencies involved
had genuine reproductive choice. The in health activities, and the need for
author argues that by building on women's participation in planning by communities.
concerns about their survival and security, Equity is an important theme throughout
it is possible to address the coercive pro- the book. The need for combining planning
natalism inherent in patriarchal techniques and political analysis is stressed,
inequalities in the family and society, as is the importance of planning by a wide
without introducing an equally coercive variety of professionals in addition to
"anti-natalist' agenda. specialist health planners.

Deborah Eade and Suzanne Williams: The Trudy Harpham and Marcel Tanner (eds):
Oxfam Handbook of Development and Urban Health in Developing Countries:
Relief Progress and Prospects
Oxford: Oxfam (UK and Ireland), 1995 London: Routledge, 1995
The first volume of this three-volume Specialists in public health and urban
reference book introduces the approaches development offer an inter-disciplinary
that inform Oxfam's work, focusing approach to urban health. They present
especially on human rights, social diversity, recent research priorities and discuss the
and strengthening local capacities. Chapter management and financing of urban health
Five, 'Health and Development' is a services,- the role of international agencies
comprehensive guide to topics such as the such as WHO^ the World Bank, UNICEF,
role of NGOs in health care, the policy and local NGOs ; trends in urban health
framework, the health needs of specific policy,- and prospects for future improve-
population groups, health-care provision, ments at strategic and conceptual levels.
and the financing, planning and evaluation
of health programmes. Chapter Six, Betsy Hartmann: Reproductive Rights and
'Emergencies and Development', also has Wrongs: The Global Politics of Population
full sections on health and nutrition, Control and Contraceptive Choice
shelter, water and sanitation, vector control, New York: Harper and Row, 1987 (revised
and food security. 1993)
A critique of the economic, political, health,
Hilary Goodman and Catriona Waddington: and human-rights consequences of population
Financing Health Care control as practised by the US population
Oxford: Oxfam (UK and Ireland), 1993 establishment, national governments, and
In what has become a highly politicised international agencies. The author argues
ethical debate, this book goes beyond the that the real solution lies not in coercive
ideological positions on public versus population-control programmes, but in the
private systems of health care and examines improvement of living standards, the
the realistic options for poor communities position of women in society, and the
to incorporate cost-recovery mechanisms quality of health and family-planning
for health and development services. services. She calls for a fundamental shift in
population policy towards the expansion
Andrew Green: Introduction to Health rather than the restriction of individual
Planning in Developing Countries reproductive choice.
Oxford: Oxford University Press, 1994
This book covers all aspects of planning for Betsy Hartmann and James K. Boyce: A
health in developing countries. Within the Quiet Violence: View From a Bangladesh
context of a PHC approach, it emphasises Village
the many factors that impinge on health, the London: Zed Books, 1983
Annotated bibliography 103

An inspiring insight into the reality of International Symposium on Participatory


villagers' lives, this book shows the nature Research in Health, this book brings
of the structural barriers faced in together a wide range of experience and
overcoming poverty and exclusion. The perspectives. It covers issues such as
perspective and priorities of people who live training, planning, research methods, and
on the margins of survival are distant from evaluation from the angles of both
the world of governments and bureaucrats, academics and practitioner. Contributors
which appears only in the form of local are drawn from all parts of the world, and
officials. The authors clearly show how from many occupations. There are case-
much mainstream development fails to studies of participatory research as well as
reach those most in need. critical analysis of the processes which
result in success and failure. The work raises
Lori Heise with Jacqueline Pitanguy and critical issues such as gender, race, and class
Adrienne Germain: Violence Against divisions, presenting these in the light of the
Women: The Hidden Health Burden different social, political, and economic
Discussion Paper No 255, Washington: The contexts in which research has taken place.
World Bank, 1994
This paper illustrates the extent and nature Anne LaFond: Sustaining Primary Health
of the violence suffered by women around Care
the world. It also describes some of the many London: Earthscan (with SCF), 1995
initiatives underway to combat the The quality and availability of health-care
problem, highlighting the ways in which services in developing countries suggest
health personnel in particular can be that support for them is not as effective as it
instrumental in this effort. might be. Programme benefits often fail to
outlive external funding, and the aim to
Najmi Kanji et al: Drugs Policy in build sustainable services remains unmet.
Developing Countries Reviewing experience in two African and
London: Zed Books, 1992 three Asian countries, the author calls for an
This book emerged from a review of the approach that addresses the wider structures
WHO Action Programme on Essential and institutions that influence investment,
Drugs, and includes material drawn from 13 planning, and management in the health
country studies. The authors find that the sector.
commoditisation of health in industrialised
countries, and the transfer of this ideology to John J. Macdonald: Primary Health Care:
the developing world, has today created a Medicine in its Place
context in which the rationalisation of drugs London: Earthscan, 1992
policies and efforts to control the activities The author presents a strong argument for
of multi-national companies are widely seen the continued relevance of the PHC
as State interference in the free market. approach, as advocated at Alma Ata. The
Analysing the political context, the authors work includes a critical appraisal of the
define a framework within which to build limitations of the medical model of health
rational drugs policies. which still predominates among health
professionals. It also argues for much better
Korrie De Koning and Marion Martin: inter-sectoral collaboration in working
Participatory Research in Health: Issues towards health goals.
and Experience
London: Zed Books, and Johannesburg: David R. Phillips and Yola Verhasselt:
National Progressive PHC Network, 1996 Health and Development
Based on the presentations at a 1993 London: Routledge, 1994
104 Development for Health

Through a series of thematic chapters and Patricia Smyke: Women and Health
regional and country case-studies, this book London: Zed Books, 1991
presents a broad but detailed description of This book examines the links between
the multi-faceted aspects of health and women, health, and development with the
development worldwide. It focuses on aim of providing a better understanding of
issues such as the effects of economic women's health issues and the root causes of
adjustment and environmental change on their problems. It offers a comprehensive
health, the possibility of extending health overview of the major health issues facing
services, socio-cultural factors in HIV/AIDS women (serious illnesses, occupational
transmission, and the health of women health hazards, threats to mental health,
beyond maternal and child health. reproductive problems, disability and age-
ing, and women as consumers of health-
Jon Rohde, Meera Chatterjee, and David related products). Addressing the question
Morley: Reaching Health For All of why women so often fail to get the health
New Delhi: Oxford University Press, 1993 care and health information they need, the
This work reviews a range of experience in author discusses legislation, education,
community health programmes aimed at environmental factors, local customs and
achieving 'Health For All'. Descriptions of practices, armed conflict and violence.
different projects reflect the many ways in Initiatives to improve women's health status
which the principles and theories of PHC are are presented, including health education,
put into practice. These are supplemented advocacy, use of the mass media, and
with critical analysis of why projects networking. The book includes case studies,
succeeded or failed. It is a valuable source of a resource guide, and suggestions for action.
case-study examples and analysis for those
struggling to implement PHC. Derek Summerfield: The Impact of War and
Atrocity on Civilian Populations: Basic
Gita Sen, Adrienne Germain, Lincoln C. Chen Principles for NGO Interventions and a
(eds): Population Policies Reconsidered: Critique of Psycho-social Trauma Projects
Health, Empowerment, and Rights London: ODI Relief and Rehabilitation
Boston, Mass.: Harvard Center for Network Paper 14,1996
Population and Development Studies and New patterns of warfare mean that 90 per
International Women's Health Coalition, cent of victims of contemporary conflict are
1994 civilians. This paper is a critique of current
This book brings together writings by methods of treating civilian trauma. It
academics, policy-makers, health argues that it is not appropriate to take
professionals, and activists in the fields of Western psycho-social models and impose
women's health and rights. From various them on other cultures. Psycho-social
perspectives and disciplines, the trauma projects must be more culturally
contributors argue that population policies sensitive; relief workers need to apply a
should assure the rights and well-being of thorough knowledge of the historical,
people who have already been born and who social, and political impact of the conflict
will inevitably be born, rather than with which they are dealing.
attempting to limit the ultimate size of the
world's population. Topics covered include
sexual and reproductive health and rights, Peter Townsend, Nick Davidson, and
the women's health movement, population Margaret Whitehead: Inequalities in
and the environment, human well-being Health: The Black Report and The Health
and freedom, empowerment, and fertility Divide
control. Harmondsworth: Penguin Books, 1992
Annotated bibliography 105

Brings together two seminal works (the within which to go about influencing
Black Report, first published in 1980, and change. The author examines areas such as
The Health Divide, 1988) on the importance the role of special interest groups, how the
of poverty in determining health. policy agenda is determined, and the arenas
Specifically examines the situation within within which government and international
the UK, looking at the differential health institutions operate. Given the speed at
and illness patterns across class and income which reforms are taking place in the public
divisions. The two reports demonstrate sector, this book offers a valuable tool with
conclusively the scientific evidence in which to understand, and to shape, the
favour of the need for action to reduce policy debate.
poverty and material deprivation in order to
improve the standard of health in the David Werner, Carol Thurman, and Jane
population. As a result, the politics of health Maxwell: Where There Is No Doctor: A
care is a strong theme throughout. Village Health Care Handbook
Palo Alto, CA: Hesperian Foundation, 1993
UNDP: Human Development Report (revised)
Oxford and New York: Oxford University One of the best-known and most widely
Press (annual) translated books on community health care,
This annual publication, taking the view this inspirational work (first published in
that development is necessarily people- 1977) explores the links between poor
centred, is a systematic attempt to identify health and social, political, and economic
and analyse those factors that can serve as exclusion. More than a self-help guide, it
indicators of human development (the places empowerment, participation, and
Human Development Index). These include social justice firmly at the centre of
not only national economic performance, development for health, arguing that 'the
but also people's access to essential services, key to health lies in the people themselves'.
and the extent to which basic human rights It has been followed by several titles based
are realised across a national society: how on this philosophy, also published by
far people are, and feel, 'secure'. In 1995, the Hesperian Foundation. Prominent examples
HDI was disaggregated, to produce the include David Werner and Bill Bower (1982),
Gender-related Development Index (GDI). Helping Health Workers Learn-, Murray
This reveals the nature and extent of Dickson (1983), Where There Is No Dentist;
women's exclusion both from the benefits of David Werner (1987), Disabled Village
economic activity (such as improved health Children-, and Susan Klein (1995), A Book
care and financial security), and from the For Midwives.
opportunity to shape public policy. The
HDR is, then, an excellent source of World Bank: World Development Report
statistical information, and also Oxford and New York: Oxford University
demonstrates some of the ways in which Press (annual)
social, economic, and political This annual publication reviews economic
marginalisation affect people's lives. performance and trends and is a valuable
source of information, as well as offering an
Gill Walt: Health Policy: An Introduction to insight into the thinking behind Bank
Process and Power lending policies. The 1993 WDR, entitled
London: Zed Books/Witwatersrand Investing in Health, is of particular interest.
University Press, 1994 It examines the interplay between human
An analysis of the many direct and indirect health, health policy, and economic
influences on policy-making in the context development, and advocates a three-
of health, this book offers a framework pronged approach to improving them.
106 Development for Health

Firstly, governments need to foster an Journals


economic environment that 'enables
households to improve their own health'. Contact
Secondly, government spending on health (published six times a year by the Christian
should be re-directed to more cost-effective Medical Commission of the World Council
programmes that do more to help the poor. of Churches)
And thirdly, governments should promote Written for the practitioner and general
greater diversity and competition in the reader. Contains descriptions of a variety of
financing of public health and the delivery of health-related projects around the world,
health services. Financing public health and along with some more critical issue-based
'essential clinical services would leave the essays.
coverage of remaining clinical services to Health and Human Rights
private insurance, or to social insurance'. (published quarterly by the Francois
Further, the Bank argues, governments Bagnaud Center for Health and Human
should encourage competition and private- Rights, Harvard School of Public Health,
sector involvement even in publicly ISSN: 1079-0969; Editor: Jonathan Mann)
financed health services. An international journal dedicated to
studying the relationships between human
WHO: Primary Health Care Report of the rights and health. The journal examines the
International Conference on Primary effects of human-rights violations on health;
Health Care the impacts of health policies on human
Alma-Ata, USSR, 6-12 September 1978, rights,- and the inextricable nature of the
jointly sponsored by WHO and UNICEF, in relationship between the promotion and
'Health for AW Series, No. 1, Geneva: WHO, protection of health and the promotion and
1978 protection of human rights.
The original document describing the vision
of Primary Health Care. Health Policy and Planning: A Journal on
Health in Development
WHO: Global Strategy for Health for All by (published quarterly by OUP in association
the Year 2000 with the London School of Hygiene and
in 'Health for AW Series, No. 3, Geneva: Tropical Medicine, ISSN: 0268-1080)
WHO, 1981 Academic journal with a strong practical
This takes the PHC strategy further, with focus. Presents both research reports and
specific details of what must be done in critical essays on a wide range of health
order to achieve its goal of Health for All by service issues. Includes a regular section of
the year 2000. 'Ten best readings on...', which is helpful in
directing readers to a wider range of
resources.
The Health Exchange
(published six times a year by the
International Health Exchange, ISSN: 1356-
3858; Editor: Isobel McConnan)
This bi-monthly magazine and its job
supplement are published in the UK by IHE,
which helps to provide appropriately trained
health workers where needed in developing
countries. The magazine explores issues,
ideas, and practical approaches to health
improvement in developing countries and
Annotated bibliography 107

provides a forum for health workers and to communicate practical lessons that can
others to share viewpoints and experiences bring the processes of health thinking and
in this area. It is intended for all those with planning closer to real conditions in the
an interest in international health field.
development, and combines features,
information about jobs and courses.
Reproductive Health Matters
(published twice a year by RHM, c/o Organisations
AHRTAG, ISSN: 0968-8080; Editor: Marge The African Medical and Research
Berer) Foundation
An international journal dedicated to An independent NGO which works to
examining reproductive health matters improve the health of the people in eastern
from a women-centred perspective, and and southern Africa, AMREF runs a wide
aiming to appeal to 'women's health variety of innovative projects with an
advocates, researchers, policy-makers and emphasis on appropriate low-cost health
health professionals at national and
care. Its programmes include community-
international level'. Each thematic issue
based PHC, training, AIDS and malaria
contains a range of academic papers, local-
prevention, family planning, and the famous
level presentations, updates on current
Flying Doctor Service. AMREF publishes a
research, reviews and further resources.
wide range of health learning, research, and
Subsidised rates are available for subscribers
practical materials.
from developing countries.
American Public Health Association
Social Science and Medicine: An The APHA International Clearinghouse is a
International Journal major centre for information on the health
(published bi-monthly by Elsevier Science of women and children. It publishes a
Ltd, ISSN: 0277-9536; Editor-in-Chief: Dr newsletter, Mothers and Children (in
Sally Macintyre) English, French, and Spanish), each issue of
An academic journal with both research and which focuses on a specific theme. The
theoretical papers covering a wide range of newsletter includes reports from
health-related themes. It provides an practitioners as well as literature reviews on
international and inter-disciplinary forum the chosen topic, and is available
for the dissemination of research findings, electronically through the World Bank's
reviews and theory in all areas of common PHNLink Network and SateLife's
interest to social scientists and health HealthNet system. The Clearinghouse also
practitioners and policy-makers. has four information databases covering
World Health Forum: An international 15,000 primary documents; education
journal of health development materials,- networking information on
(published quarterly by WHO, ISSN: 0251- hundreds of relevant organisations
2432, available in Chinese, English, French, worldwide; and periodicals.
Russian, and Spanish editions)
Appropriate Health Resources and Action
A quarterly record of ideas, arguments, and
Group
experiences contributed by a wide spectrum
AHRTAG aims to disseminate practical
of health professionals worldwide.
information on PHC and disability issues,
Information ranges from critiques of
and provide an information and enquiry
conventional health policies, through
service for community health workers. It
lessons from project failures, to success
runs a resource centre which contains over
stories illustrating the value of a new
19,000 books, journals, training manuals,
approach to technical solution. The goal is
Annotated bibliography 107

provides a forum for health workers and to communicate practical lessons that can
others to share viewpoints and experiences bring the processes of health thinking and
in this area. It is intended for all those with planning closer to real conditions in the
an interest in international health field.
development, and combines features,
information about jobs and courses.
Reproductive Health Matters
(published twice a year by RHM, c/o Organisations
AHRTAG, ISSN: 0968-8080; Editor: Marge The African Medical and Research
Berer) Foundation
An international journal dedicated to An independent NGO which works to
examining reproductive health matters improve the health of the people in eastern
from a women-centred perspective, and and southern Africa, AMREF runs a wide
aiming to appeal to 'women's health variety of innovative projects with an
advocates, researchers, policy-makers and emphasis on appropriate low-cost health
health professionals at national and
care. Its programmes include community-
international level'. Each thematic issue
based PHC, training, AIDS and malaria
contains a range of academic papers, local-
prevention, family planning, and the famous
level presentations, updates on current
Flying Doctor Service. AMREF publishes a
research, reviews and further resources.
wide range of health learning, research, and
Subsidised rates are available for subscribers
practical materials.
from developing countries.
American Public Health Association
Social Science and Medicine: An The APHA International Clearinghouse is a
International Journal major centre for information on the health
(published bi-monthly by Elsevier Science of women and children. It publishes a
Ltd, ISSN: 0277-9536; Editor-in-Chief: Dr newsletter, Mothers and Children (in
Sally Macintyre) English, French, and Spanish), each issue of
An academic journal with both research and which focuses on a specific theme. The
theoretical papers covering a wide range of newsletter includes reports from
health-related themes. It provides an practitioners as well as literature reviews on
international and inter-disciplinary forum the chosen topic, and is available
for the dissemination of research findings, electronically through the World Bank's
reviews and theory in all areas of common PHNLink Network and SateLife's
interest to social scientists and health HealthNet system. The Clearinghouse also
practitioners and policy-makers. has four information databases covering
World Health Forum: An international 15,000 primary documents; education
journal of health development materials,- networking information on
(published quarterly by WHO, ISSN: 0251- hundreds of relevant organisations
2432, available in Chinese, English, French, worldwide; and periodicals.
Russian, and Spanish editions)
Appropriate Health Resources and Action
A quarterly record of ideas, arguments, and
Group
experiences contributed by a wide spectrum
AHRTAG aims to disseminate practical
of health professionals worldwide.
information on PHC and disability issues,
Information ranges from critiques of
and provide an information and enquiry
conventional health policies, through
service for community health workers. It
lessons from project failures, to success
runs a resource centre which contains over
stories illustrating the value of a new
19,000 books, journals, training manuals,
approach to technical solution. The goal is
108 Development for Health

and reports focusing on the practical aspects of governments and leaders to the people.
of PHC and community-based IPHC facilitates information-sharing among
rehabilitation, and compiles a bibliographic its membership through a structure of
database (with AHRTAG Update available regional representatives around the world.
on subscription). AHRTAG publishes
International Federation and International
briefing papers, booklets, resource lists, and
Committee of the Red Cross
four international newsletters [AIDS Action
The ICRC is uniquely mandated to offer
ISSN 0953 0096; CBR News ISSN 0963-
protection and assistance to victims of war
5556; Child Health Dialogue ISSN 0950
and armed conflict, by means including the
0235; and Health Action ISSN 0969 479X),
provision of medical aid. It has considerable
which are all available free of charge to
experience in the field of war surgery and the
readers in the South.
psycho-social aspects of conflict.
Health, Empowerment, Rights, and Publications are available in several
Accountability languages, including English and French.
HERA is an international group of women's
International Women's Health Coalition
health activists working together to ensure
IWHC is a non-profit organisation that
implementation of the Programme of
works with individuals in Asia, Africa, and
Action produced by the International
Latin America to promote women's
Conference on Population and
reproductive health and rights. IWHC
Development (ICPD) held in Cairo in 1994.
provides technical, moral, and financial
Building on the Cairo Consensus, HERA
support to reproductive health service-
advocates, designs, and implements providers and advocacy groups in a number
strategies to guarantee sexual and of countries, publishes books and position
reproductive health and rights, within the papers, convenes meetings on new or
broader context of human rights and neglected issues in women's sexual and
sustainable development. reproductive health, and acts directly to
The Inter-African Committee on influence the work of population and health
Traditional Practices Affecting the Health professionals, national governments, and
of Women and Children international agencies.
An NGO based in Ethiopia and active in 23
Latin American and Caribbean Women's
countries, which has campaigned
Health Network
vigorously against the practice of female
Organises region-wide activities and
genital mutilation (FGM), and has
publishes a quarterly magazine, Women's
conducted research on other harmful
Health Journal (in Spanish: Revista Mujer
practices relating to childbirth and delivery,
Salud), which links about 2,000 groups and
social and nutritional taboos, the forced
individuals worldwide, and is an
feeding of women, early childhood
international forum for researchers and
marriages, and teenage pregnancy. women's health activists. The magazine
International People's Health Council addresses all aspects of women's health, and
IPHC is an informal network of groups and provides information about reproductive
movements committed to working for the health and rights, pregnancy and childbirth,
health and rights of disadvantaged people, sexuality, HIV/AIDS, and occupational
and their liberation from poverty, hunger, health.
and unfair socio-economic structures. Its
Medecins Sans Frontieres
members believe that health for all will be
MSF offers assistance to populations in
best achieved through participatory
distress, to victims of disasters, to victims of
democracy, equity, and the accountability
armed conflict, irrespective of race, religion,
Oiganisations 109

creed, or political affiliation. MSF is often United Nations Children's Fund


the operational partner of UNHCR in UNICEF has a universal mandate to
refugee-related emergencies. MSF has promote the survival, protection and
published a series of specialised documents development of children. It was the lead
providing recommendations and agency in developing the 1989 UN
information on procedures to assist doctors Convention on the Rights of the Child and
and paramedics working in isolated and the 1990 World Summit for Children.
often precarious conditions. UNICEF collaborates closely with other UN
agencies in programmes concerning health,
The Medical Foundation for the Care of
nutrition, education, women and maternal
Victims of Torture
health, and public and environmental
A charity registered in the UK providing
health. UNICEF publishes widely, the most
medical treatment, practical assistance,
well-known of its annual publications being
counselling and psychotherapy to survivors
State of the World's Children and The
of torture. It also provides training for health
Progress of Nations, both authoritative
professionals and publishes a range of
sources of information which give an
reports, including the recent Guidelines for
overview of health-related issues from the
the examination of survivors of torture.
perspective of children.
Save the Children Fund UK
United Nations High Commissioner for
SCF UK publishes research and working
Refugees
papers, and development manuals which are
UNHCR is concerned with the
designed as short practical guides for
international protection of refugees, defined
development practitioners. Examples
as persons who owing to a well-founded fear
include Toolkits: A practical guide to
of persecution for reasons of race, religion,
assessment, review and evaluation (1995);
nationality, social group, or political
The Management of Health and Nutrition
opinion are outside the country of their
in Emergencies (1996); Children, Disability,
nationality; and the promotion of durable
and Development (1994).
solutions for their problems. Publishes the
Teaching Aids at Low Cost annual State of the World's Refugees and
A UK NGO which distributes low-cost and various guidelines, for example on
appropriate books, slides, and teaching reproductive health (1996), sexual violence
materials to developing countries by mail (1995), refugee children (1994), disabled
order. Topics in the TALC catalogue include refugees (1992), and refugee women (1991).
Health Care Services,- Mother and Child
United Nations Population Fund
Health; Nutrition and Child Growth; AIDS
UNFPA is the lead UN agency on
Education and Communication; Education
population issues, such as reproductive
and Communication,- Disability;
health, fertility, mortality, and demography,-
Appropriate Technology. TALC has also
and on follow-up to the 1994 International
developed small 'libraries' collections of
Conference on Population and
books aimed at pharmacies, district
Development, held in Cairo. Its magazine
hospitals, district health workers, village
Populi (available in English, French, and
and community workers, or medical
Spanish) is free of charge, and is a useful
students. Titles offered by TALC include:
source of information from many parts of
Where there is No Doctor-, Where there is No
the world. Its annual publication The State
Dentist; A Book for Midwives-, UNICEF
of World Population is a summary and
State of the World's Children-, Stepping
overview of the main issues and trends in
Stones from Strategies for Hope; Women
the field.
and HIV/AIDS.
110 Development for Health

The World Health Organisation Addresses of publishers and other


WHO's objective is 'the attainment by all organisations
citizens of the world ... of a level of health
that will permit them to lead a socially and African Medical and Research Foundation,
economically productive life'. Its Global PO Box 30125, Nairobi, Kenya. Fax: +254
Strategy to achieve 'Health for All by the (0)2 506112.
Year 2000' is based on the primary health
Allison and Busby, 5 The Lodge, Richmond
care approach (PHC). WHO has the leading
Way, London W12 8LW, UK.
role in international standard-setting in the
field of health. It works mainly with American Public Health Association
governments to reinforce their health (APHA) International Clearinghouse, 1015
systems, and also promotes policy-related Fifteenth Street NW, Washington DC
research on all aspects of health, as well as 20005, USA. Fax: +1 (0)202 789 5600.
the needs of particular population groups.
Appropriate Health Resources and Action
WHO has a wide range of publications, from Group (AHRTAG), 29-50 Faringdon Road,
highly specialised books and journals to London EC1M3JB, UK. Fax: +44 (0)171371
those for the general reader. It also produces 7104.
newsletters, training, and advocacy
materials (often free of charge and published Earthscan Publications, 120 Pentonville
in English, French, and Spanish) for health Road, London Nl 9JN, UK. Fax: +44 (0)171
workers and non-specialists who deal with 278 1142.
health-related issues. Examples are the
briefing pack on Female Genital Mutilation Elsevier Science, The Boulevard, Langford
(FGM), and The Mother-Baby Package Lane, Kidlington, Oxford OX5 1GB, UK.
produced by the Maternal Health and Safe
Harper and Row, 10 East 53rd Street, New
Motherhood Programme. Its annual
York, NY 10022, USA.
publications are The World Health Report
and World Health Statistics Annual. Harvard School of Public Health, 8 Story
The WHO World Wide Web home page Street, 5th Floor, Cambridge MA 02138,
(http://www.who.ch) offers electronic USA. Fax: +1 (0)617 496 4380.
access to information held at its Health, Empowerment, Rights and
Headquarters (such as statistics, Accountability (HERA), c/o International
publications, conferences), access to the six Women's Health Coalition, 24 East 21st
WHO regional offices, and to the WHO Street, 5th Floor, New York, NY 10010,
Library database (WHOLIS). Apart from USA. Fax: +1 (0)212 979 9009.
WHO publications, this has extensive
holdings of books, monographs, and other The Hesperian Foundation, 2796
documents,- and 3,000 periodical titles. Middlefield Road, Palo Alto, CA 94306,
USA. Fax: +1 (0)415 325 9044.

Inter-African Committee on Elimination of


Harmful Practices, PO Box 3001, Addis
Ababa, Ethiopia.

International Committee of the Red Cross,


19 avenue de la Paix, 1202 Geneva,
Switzerland. Fax: +41 (0)22 734 7979.
110 Development for Health

The World Health Organisation Addresses of publishers and other


WHO's objective is 'the attainment by all organisations
citizens of the world ... of a level of health
that will permit them to lead a socially and African Medical and Research Foundation,
economically productive life'. Its Global PO Box 30125, Nairobi, Kenya. Fax: +254
Strategy to achieve 'Health for All by the (0)2 506112.
Year 2000' is based on the primary health
Allison and Busby, 5 The Lodge, Richmond
care approach (PHC). WHO has the leading
Way, London W12 8LW, UK.
role in international standard-setting in the
field of health. It works mainly with American Public Health Association
governments to reinforce their health (APHA) International Clearinghouse, 1015
systems, and also promotes policy-related Fifteenth Street NW, Washington DC
research on all aspects of health, as well as 20005, USA. Fax: +1 (0)202 789 5600.
the needs of particular population groups.
Appropriate Health Resources and Action
WHO has a wide range of publications, from Group (AHRTAG), 29-50 Faringdon Road,
highly specialised books and journals to London EC1M3JB, UK. Fax: +44 (0)171371
those for the general reader. It also produces 7104.
newsletters, training, and advocacy
materials (often free of charge and published Earthscan Publications, 120 Pentonville
in English, French, and Spanish) for health Road, London Nl 9JN, UK. Fax: +44 (0)171
workers and non-specialists who deal with 278 1142.
health-related issues. Examples are the
briefing pack on Female Genital Mutilation Elsevier Science, The Boulevard, Langford
(FGM), and The Mother-Baby Package Lane, Kidlington, Oxford OX5 1GB, UK.
produced by the Maternal Health and Safe
Harper and Row, 10 East 53rd Street, New
Motherhood Programme. Its annual
York, NY 10022, USA.
publications are The World Health Report
and World Health Statistics Annual. Harvard School of Public Health, 8 Story
The WHO World Wide Web home page Street, 5th Floor, Cambridge MA 02138,
(http://www.who.ch) offers electronic USA. Fax: +1 (0)617 496 4380.
access to information held at its Health, Empowerment, Rights and
Headquarters (such as statistics, Accountability (HERA), c/o International
publications, conferences), access to the six Women's Health Coalition, 24 East 21st
WHO regional offices, and to the WHO Street, 5th Floor, New York, NY 10010,
Library database (WHOLIS). Apart from USA. Fax: +1 (0)212 979 9009.
WHO publications, this has extensive
holdings of books, monographs, and other The Hesperian Foundation, 2796
documents,- and 3,000 periodical titles. Middlefield Road, Palo Alto, CA 94306,
USA. Fax: +1 (0)415 325 9044.

Inter-African Committee on Elimination of


Harmful Practices, PO Box 3001, Addis
Ababa, Ethiopia.

International Committee of the Red Cross,


19 avenue de la Paix, 1202 Geneva,
Switzerland. Fax: +41 (0)22 734 7979.
Publishers and other organisations 111

International Federation of Red Cross and Fax:+44 (0)181307 4440.


Red Crescent Societies, PO Box 372,1211
Geneva 19, Switzerland. Fax: +41 (0)22 833 Penguin Books, Bath Road,
0395. Harmondsworth, Middlesex UB7 0DA, UK.
Fax:+44 (0)181 8994099.
International Health Exchange, 8-10
Dryden Street, London WC2E 9NA, UK. Praeger Publishers, 88 Post Road, Westport
Fax:+(44)0171379 1239. CT 06881, USA.

International People's Health Council Routledge, 11 New Fetter Lane, London,


(IPHC) Information can be obtained from EC4P4EE, UK. Fax: +44(0)171 8422303.
the Hesperian Foundation, or from CISAS,
Save the Children Fund UK, Mary
Apartado Postal 3267, Managua, Nicaragua.
Datchelor House, 17 Grove Lane, London
Fax:+505 (0)2 24098.
SE5 8RD, UK. Fax: +44 (0)171 222 7500.
International Women's Health Coalition,
Teaching Aids at Low Cost (TALC), PO Box
777 UN Plaza, New York, NY 10017, USA.
49, St Albans, Herts AL1 4LX, UK. Fax: +44
Fax:+1(0)212 687 8633.
(0)1727 53869.
Kali for Women, Bl/8 Hauz Khas, New
UN Development Programme (UNDP), One
Delhi 110016, India. Fax: +91 (0)11 686
United Nations Plaza, New York, NY
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