AIDS EDUCATION IN A MULTICULTURAL SOCIETY

AIDS EDUCATION IN A MULTICULTURAL SOCIETY

by Sasha Sadan

In October, 1994, the Third Biannual International Course on Planning, Designing, Implementing and Evaluating Appropriate Intervention Programs to Reduce the Risk of HIV Transmission will be held at the Aharon Ofri International Study Centre in Kibbutz Ramat Rahel outside of Jerusalem. In this course with a grassroots approach, health and education professionals are encouraged to come up with ideas for educational programs for the prevention of the AIDS (HIV) virus which will work in their own communities.

On December 1, International AIDS Day, there appeared on Israeli television a heated debate about correct approaches to AIDS prevention in the media. The debate was between two religious Jewish educators and a group of secular Jewish youth. The TV advertisement in question showed a fully clothed couple of modern, secular young adults with the voice-over saying, "Do you know that every time you have sex with your boyfriend you are having sex with his former girlfriend (another couple appears on the screen), and the former boyfriend of the former girlfriend (another couple appears), and the former boyfriend of the former girlfriend of the former boyfriend of the former girlfriend (many couples appear on the screen) ... maybe one of them has AIDS." Then, with no sound, a picture of a condom appears on the screen with the caption: "Fight AIDS for the life of the human race" (but the words have a double meaning in Hebrew and can also mean: "Fight AIDS for a humane sex life").

The religious educator was quite adamant that this was extremely offensive to religious people on the grounds that the ad implied a permissive attitude toward premarital sex. He suggested something else. He said the advertisement should advocate: "Love, truth, loyalty, distance and abstinence until marriage."

The secular young people were equally adamant that this would be totally ineffective and demanded sex education and condomats in every high school instead, as a measure against AIDS.

The attempted discussion degenerated into a futile argument, strongly demonstrating the disparity between two sub-cultures within the same society. There is no question that the messages which may have been relevant and appropriate to the group of secular youth were totally inappropriate for the religious sector. Problems of communicating in multicultural societies exist all over the world. Israel is no exception. With sensitivity and experience these problems can be overcome.

Shalom Magazine's reporter accompanied Dr. Ronny Shtarkshall, Head of Behavioural Research and Health Education at the Braun School of Public Health and Community Medicine of the Hebrew University and Hadassah Medical Organization in Jerusalem, on a day of teaching. He and a team of colleagues encourage social workers, doctors, nurses and community workers to come up with AIDS prevention programs that work. The emphasis is not on just making information available, but much more so on getting people to use what they learn.

Shtarkshall contends that this argument has strong bearing on the international cooperation to developing countries in their efforts to prevent the spread of AIDS virus (Human Immunodeficiency Virus - HIV). "We should not transfer prevention programs from one country to another, not only because of the different needs and conditions, but also because of cultural uniqueness. The problems are magnified in multicultural societies,such as immigrant societies like Israel, multi-tribal societies, and countries where different religions prevail."

The team from Hadassah does just that in conjunction with courses given under the auspices of MASHAV, the Centre for International Cooperation of the Israeli Ministry of Foreign Affairs. Dozens of experts from developing countries participate in twice-yearly six-week courses called Planning, Designing, Implementing and Evaluating Appropriate Intervention Programs to Reduce the Risk of HIV Transmission. The course does not train the experts in the use of Israel-developed programs, but uses them as an example for program development. At Ramat Rahel in a practical approach, the staff encourages health and education professionals to come up with ideas for programs which will work in their own communities.

"It is true that we utilize the same general principles we use in our own programs for Israelis, but that is because they deal with the deeper issues of HIV prevention. Emphasis is not on awareness and dissemination of information, but on the more difficult problems of changing attitudes and getting people to utilize what they learn in making behavioural decisions, to enable people to take responsibility for their own health. Their job is to define the needs, constraints and the cultural environment and to use the experience gained here and some building blocks to build innovative programs.

Shtarkshall is a big bear of a man with white hair, though he is in his fifties. He is a slow, deliberate speaker who pause to let his words sink in. He's discovered that his white hair makes some people less willing to open up to him. For other it is a reassuring promise that he ha experience and wisdom. This personal experience is used to demonstrate that any person who works through communicating with others must take into account how s/he is perceived by others. it also demonstrates that one person cannot "win them all" in an educational process involving emotional issues and that team work is essential.

In his lectures, Shtarkshall uses some traditional techniques such as questionnaires and slides, but over and over again he conveys a different message from just the content of what is discussed: Very little is learned unless there is analysis of what you are doing and then integration. If people are to absorb messages and integrate them into their behaviour the messages have to be given in ways that makes them available to the listener. The educational process is aimed at opening people up to the message and letting them be inspired.

The 28 course participants sit in a circle in a conference room, and Shtarkshall, a casual figure in blue jeans and sandals, moves back and forth, going around the group making eye contact. Clearly he wants everyone present involved in the action. He asks each person to write a little on two subjects: what they know about AIDS, and what they would like to know. Everyone knows something, says Shtarkshall. And even professionals in the field of AIDS have questions. It's okay, his body language and words suggest, to ask anything you want, Nobody need be embarrassed about what s/he doesn't know. Shtarkshall pays attention to the fact that English is not necessarily the first language of everyone in the group. "It's not easy," he encourages, "but just write one thing."

The groups divide into teams to consider what they most want to know about AIDS, and to come up with just one question. The teams go outdoors for a 30-minute conference. Each group gets to ask only one question. The sprinkling of people sit on the green lawn of Kibbutz Ramat Rahel and compare notes. The sun shines warm on their backs. There will be a coffee break soon and little cakes and chatter. A straight lecture might have resulted in 28 polite but basically bored listeners. instead there is a buzz of discussion. Everybody has something to say.

The teams come back with their questions: Is it true that First World countries are benefitting from AIDS as a means of Third World birth control? How many of those infected with HIV virus will actually get AIDS? What are the factors which turn an HIV carrier into someone sick with AIDS? Is it up to the AIDS sick individual to tell his/her partner that s/he has the disease or the duty of the health professional to inform sexual partner(s)?

"The First World is not benefitting from AIDS," notes Shtarkshall. "One of the big lessons of AIDS is that when new diseases appear, and they will, we all have to deal with them. I believe we are lucky with AIDS, because it is relatively difficult to become infected. We can still tackle it. The disease is not borne of the air. In most countries you have to do something conscious and deliberate in order to be exposed to the virus, so it is up to our consciousness raising and educational efforts to slow its spread. But first governments and nations have to face the facts and set their priorities straight. There are countries that give out false statistics on AIDS for fear of what might happen to their tourist trade. Some countries ignore the problem.

"Over 9O% of those infected with HIV virus will develop AIDS. The time lag can be six months or it can be 12 years. One of the most important research questions we face is what determines the development of the disease. Maybe we could reach a situation in which you could be an AIDS carrier and still die of old age before actually suffering from the disease.

"Some factors changing an HIV carrier into someone sick with AIDS as currently delineated are, for example, a weak immune system, the presence in the body of another germ from the mycroplasm family, some genetic factors, gender, and age. It seems that sexually transmitted diseases are a cofactor in both the transmission of the AIDS virus and in its development into AIDS."

As for telling your sex partner, Shtarkshall says the responsibility for telling a partner in some countries is up to those supplying medical treatment. This question about notifying sex partner(s) is turned into a discussion of the different cultural traditions concerning the relative rights of the individual and the public, the role of the health professionals and their duties toward the patient on the one hand, and society on the other. The emphasis is on the need and the ability to combine individual requirements with public interest within different cultural traditions. "It is up to us to design training materials for professionals in ways that will be both beneficial and acceptable to the various countries."

Shtarkshall answers the questions and then turns the discussion upside- down, questioning his own methods. "We have done two things here. First, there was some introspection. Remember that many people will not put on paper what comes to mind." Shtarkshall pauses and adds, "Some of the people you want to reach won't be literate."

Then he goes for his main point: "There is a grave mistake made in the belief that we learn from experience." Shtarkshall shakes his head "no" as he says this. "We learn from analyzing and integrating what we experience. This is true whether the person is an individual attempting to avoid HIV infection or an expert trying to learn experiential methods to be used in AIDS prevention programs."

One of the main problems in dealing with AIDS, says Shtarkshall, is that "talking about it is a lot like putting your hands on someone's private parts. But there is a way to talk about it without offending people and, more important, getting them to act, for themselves and for the community," he says. "We have to deal with sexual behaviours in general and not only with AIDS. Sexual responsibility and sexual health are an integral part of the fight against AIDS. You cannot isolate the efforts to stem the spread of AIDS from issues of sexuality, even if this fact imposes additional hardship for the educator and the target population."

One example is the way in which the subject has been approached in Israel when dealing with diverse communities. The specific population of Jewish immigrants from Ethiopia, 15,000 of whom were airlifted to Israel in 1991, is a case in point. They have been taught about AIDS prevention through their culture, which is close-knit and religious perhaps to a higher degree than other sections of the diverse Israeli society. Tradition and modesty are highly prized and direct discussion of sexual issues is not allowed. The pictures used as teaching aids were developed by a joint team

(see illustrations): experts on AIDS and those who came from the Ethiopian community. Shtarkshall stresses that to communicate with a community, you need people from within the community. Without these partners, the AIDS expert will get nowhere. "We are talking about a real partnership," he emphasizes.

Several new teaching aids have been developed, some of which were very specific to this community, while others could be generalized for use with other hard-to-reach groups. A set of posters were developed in which several layers of visual cues were used. The direct messages, teaching about HIV/AIDS and its prevention, had to be adapted to the cultural norms and the level of knowledge of the immigrants, were also checked for possible stigmatizing messages and indirect counter-messages were introduced.

The pictures used included a scene of a couple in a sexual situation. Openness in talking about intercourse does not come easily for the recently arrived Ethiopian community. So the picture does not show a dark-skinned Ethiopian couple. It shows two light-skinned adults. The change is of great importance. This way the personal discomfort of the viewer is minimized and s/he can focus on the message that heterosexual intercourse can transmit HIV. The viewer can peek at the picture and not feel threatened by embarrassment.

There had been much discussion and the picture had been redrawn several times in order to get the couple covered up enough. What was acceptable modesty for many secular Israelis was unacceptable for the new Israeli community from Ethiopia. Through discussion a working picture was achieved with the blanket covering the lovers almost to their shoulders. But there is no doubt about what they are doing and the teaching purpose is clear.

Shtarkshall tells the story about several African health workers, participants in an Israeli course on AIDS education, who teamed up to develop a program on AIDS prevention. High on their priority list was a custom which is widely spread, in different forms, not only in Africa but in many parts of the world. A newly widowed woman is required to have intercourse with her husband's brother or cousin before she is able to remarry. But what if her husband died of AIDS and she is already a carrier? "How do we deal with this issue?" was the question raised in consultation. The secret, says Shtarkshall, was in rephrasing the question. "What is the meaning of the custom? What part of the sexual act is significant? Is the point of the act to enter the women or to ejaculate inside her? If it was the entrance, then condoms could be used. If the semen was important, then there was a totally different problem."

The fact that the health workers did not know the answer should hardly surprise anyone. People from within a culture rarely stop to think about the meaning of a custom. Even if they do they have difficulty asking about them, especially if they concern very private, delicate matters. "This must be a directed, highly sophisticated effort," he emphasizes. It is not necessary to destroy an important tradition, but it is essential to discover the real reasons behind traditions in order to plan a program. It is necessary to try to discover the inner meaning of a custom and its details, which will enable us to weave the needed changes into the cultural framework. It really boils down to true respect for the people and the communities with which you work. It is easy, especially within cultures in transition, or multicultural societies, to look down on customs of others as "primitive," "superstitious," or even "unmedical" or "irrational." This is a grave mistake that each of us has to be wary of at all times.

Health workers have to get across sophisticated and delicate issues, and both kinds of messages can be handled if you know the community with which you are dealing, if you think in terms of cultural norms and if you use every resource you have. Shtarkshall says that the only people who can come up with the right message for a particular community, whether it's refugees or a street gang or shy young women who would not dream of talking about sex, are the people from that group or community. The so-called experts can only help if they have the partnership of those they want to reach.

Even among up-to-date Israelis, he says, there is a common attitude among young women from traditional environments that they don't "have" sex, meaning they do not see themselves as seeking sexual contact. Sex is something that happens to them. Consequently, it doesn't fit into their concept of themselves for them to take active preventive steps on the subject. The AIDS health worker who wants these women 'to do something" is working against their feelings about themselves. But, says Shtarkshall, these women do not have to take an active step. They may be open to the idea of asking a prospective partner to do something. He can use a condom. The women can be coaxed to signal to their partner that this is what they want.

Shtarkshall repeats to the course participants that they will have to come up with their own educational methods. You cannot use worksheets, he says, for instance, when the literacy rate is less than 85%. It is probably also an unproductive way of approaching street kids. "Part of their culture is to scorn anything intellectual. You have to speak their language and know their concerns, how they think, how they talk, what turns them off," he adds. "If you work with adolescents, make them equal partners. If you have a generation gap, you need a cultural mediator." Such mediators come from the target population and know their norms, what they believe in, what they like to do and what is taboo.

"Many times these people need outside experts not only to bring in the right educational methodology and technology, but also to ask the probing questions which are 'transparent' or 'unallowed' for people from within the group. You see, to tackle the problems of AIDS properly we need both insight and outsight working in tandem". He smiles, "If we examine our own work, as everyone should do from time to time, we may find that this is the true meaning of international cooperation.

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