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David Dickinson - Changing the Course of AIDS: Peer Education in South Africa and Its Lessons for the Global Crisis

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Changing the Course of AIDS: Peer Education in South Africa and Its Lessons for the Global Crisis
Author:
David Dickinson
Publisher:
Cornell University Press
Genre:
Books / Politics
Year:
2011
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Changing the Course of AIDS is an in-depth evaluation of a new and exciting way to create the kind of much-needed behavioral change that could affect the course of the global health crisis of HIV/AIDS. This case study from the South African HIV/AIDS epidemic demonstrates that regular workers serving as peer educators can be asor even moreeffective agents of behavioral change than experts who lecture about the facts and so-called appropriate health care behavior. After spending six years researching the response of large South African companies to the epidemic that is decimating their workforce as well as South African communities, David Dickinson describes the promise of this grassroots interventionworkers educating one another in the workplace and communityand the limitations of traditional top-down strategies.

Dickinsons book takes us right into the South African workplace to show how effective and yet enormously complex peer education really is. We see what it means when workers directly tackle the kinds of sexual, gender, religious, ethnic, and broader social and political taboos that make behavior change so difficult, particularly when that behavior involves sex and sexuality. Dickinsons findings show that people who are not officially health care experts or even health care workers can be skilled and effective educators. In this book we see why peer education has so much to offer societies grappling with the HIV/AIDS epidemic and why those interested in changing behaviors to ameliorate other health problems like obesity, alcoholism, and substance abuse have so much to learn from the South African example.

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A VOLUME IN THE SERIES

The Culture and Politics of Health Care Work

edited by Suzanne Gordon and Sioban Nelson

A list of titles in this series is available at www.cornellpress.cornell.edu.

CHANGING THE COURSE OF AIDS

Peer Education in South Africa and Its Lessons for the Global Crisis

DAVID DICKINSON

FOREWORD BY CHARLES DEUTSCH

ILR PRESS

AN IMPRINT OF

CORNELL UNIVERSITY PRESS

ITHACA AND LONDON

CONTENTS

FOREWORD

A great deal has been written in the last two decades about HIV/AIDS, especially on the pandemic afflicting Southern Africa. What does this book add, not merely to our library of continuing tragedy, but to the hope that we can someday turn it into an archive helping us learn from the past?

In Southern Africa we are barely making a dent in rates of new infection. Prevention has always been grossly underfunded, and remains so. But now it is considered a priority to combine biomedical, structural, and social/behavioral prevention strategies. Two decades ago some virologists were confident that adequate investment in research would by now yield a vaccine preventing new HIV infection. Today, leading scientists say we may never have one. No one blames the scientists or the level of investment; science cant be forced. Similarly, structural solutionsalleviating poverty and providing equitable health care and educationare not things we can expect to happen quickly, in Southern Africa or anywhere else.

But expectations for social and behavioral strategies have been viewed through a different lens. The rhetoric of policymakers and donors is behavior change communication (BCC) and its staples are messages. It derives from economists who posit rational actors who will act in their self-interest if they can only be given accurate information. Its leading advocates are mass media specialists who claim they can sell anything with the right images, jingles, and spokespersons. From a very different direction, preachers spout fire and brimstone and tell people what behavior God insists on; teachers pronounce facts about biology from the front of the room. None of these, individually or in chorus, has worked yet; and the suspicion is dawning that prevention education needs its perspective adjusted for realism.

Behavior changes such as delaying sexual debut, encouraging secondary abstinence, reducing the number of concurrent partners, and consistently using condoms are largely dependent on deeper changes in norms that sanction violence against women, transactional sex, and mens right to (and pride in) multiple sexual partnerships. If we expect broad and quick changes in these and related behaviors (drinking and drug use, for example) that are freighted with pleasure, power, custom, tradition, and economic desperation, then we will try the wrong things, and everything we try will look like a failure.

Yet norms and traditions of all kinds do change, everywhere and all the time. Certainly technologies such as computers and cell phones provoke dramatic changes, but changes in norms concerning gender, race, and ecology, different across countries and cultures, are no less dramatic. Not so many years ago, the streets of U.S. cities were decorated with dog litter and no one would have believed theyd all soon be walking their dogs with a plastic bag at the ready. We cant always see change coming and pinpoint the reasons, but it usually happens through a dynamic interplay between laws and policies, technologies, and our conversations. Fire hoses were turned against relatively few civil rights activists, but as their news filled the media, churches and universities conversations about them kept rippling outwards. The words we use, and the words we stop using, matter. Indeed, activists supporting each of these changes found various ways to stimulate and guide conversations at dinner tables and water coolers everywhere.

Because AIDS is most closely associated with sex and death among people whose traditions and institutions (including schools) refrain from mentioning either, we have not made good use of our conversations. Since people of all ages usually talk, listen, think, and learn about sensitive issues such as sexuality on the quiet, with people like themselves, peer education is a leading social strategy to change the conversations and norms that surround behavior. What has been blurred by the myopia around BCC is that education is much more than information transfer and message transmission. Educators are better evaluated by the questions they ask than the answers they give. In this context, education is about unsettling the unexamined beliefs and traditional behaviors that are killing people, and doing these things, sometimes a little at a time, whenever the opportunity arises.

David Dickinson asks the question: How can we inject into the busy, distracted, difficult lives of the least educated and poorest among us the opportunity, and eventually the habit, to think critically about their social norms and behaviors; that is, about how to keep themselves and their loved ones healthy in a terribly dangerous environment? The answer is: Purposefully, persistently, with system and intent, through judicious infiltration of the social networks people live and act in. It requires intensive, sustainable face-to-face social strategies in which trusted people listen to what is being said and believed, and respond with stories that are not only accurate but also memorable and credible, and can compete successfully with the myths and beliefs that support dangerous norms. In some settings, such as schools, churches, mosques, and sports programs, peer education can be structured and scheduled. In other contexts, such as most workplaces, it is more informal and impromptu, but with many predictable opportunities to be prepared for.

It is the why, what, and how of these latter contexts that Dickinson so ably addresses. He is especially eloquent about the need to work below the surface and behind the scenes, where peer education has few rivals. He documents aspects of the struggle against AIDS that are not usually subject to disciplined scrutiny. He culls from the experiences and wisdom of hundreds of dedicated adult peer educators across South Africa, reconciling and contrasting their insights with theories that have been the basis of social strategies to contain and control new infection and test and treat those currently infected.

This book rests on a confidence in horizontal learning and a respect for what people who dont have much formal education can know and do for one another. Those beliefs are not widely and deeply owned by decision makers in the United States or South Africa. As we cast about for more realistic ways to approach prevention, and settle on strategies that help people think and talk together about what they believe and what they do, these insights into peer education at the workplace will remind us that we have the resources in our midst to change our conversations, our norms, and our behavior.

CHARLES DEUTSCH, SCD

Harvard School of Public Health

ACKNOWLEDGMENTS

This book was a pleasure to write. I learned a great deal. For that I am grateful to many people.

Above all, I would like to thank the many HIV/AIDS peer educators who appear in this book (under pseudonyms) or contributed to the research in so many different ways. It would be hard to find a kinder, more interesting, or more dedicated group of people to research and write about. That, however, is not why I wrote a book about peer educators. I wrote it because I believe that peer education is a critical component of any effective response to HIV/AIDS and, indeed, to changing behavior beyond the challenge of AIDS. As such, the peer educators in this book are not simply research subjects but colleagues with whom I have worked and from whom I have learned. One peer educator whom I will name, since we have worked and published together, is Duncan Kabelo Kgatea who has taught me more than any other individual peer educator. Duncan,

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