World Disasters Report 2014 – Chapter 6

Culturally sensitive public health: the HIV/AIDS disaster and beyond

This chapter shows that different cultures - ‘biomedical’ public health versus ‘traditional’ medicine - interact. It is important to take account of this.

The relationship between disasters and health is twofold. Firstly, a hazardous event, social crisis or war might corrupt living conditions such that diseases, injuries or other acute health impairments occur.

Secondly, diseases themselves can provoke disastrous conditions - the HIV/AIDS pandemic, for example. From a public health perspective, such disasters are complex because a political process is needed to designate them so.

In humanitarian and public health action, the importance of what are vaguely labelled ‘communities’, ‘local response’ and ‘resilience’ have been widely acknowledged.

It is essential for humanitarian action to identify those who are, or have become, particularly vulnerable.

In its code of conduct, the IFRC also recognizes local culture, practices, knowledge and capacities. With millions of volunteers, the IFRC has incorporated cultural sensitivity into its policies and practice, describing them as its “eyes and ears”, as an early warning system.

Humanitarian assistance and public health schemes are also expressions of culture.

Most experts believe the HIV pandemic could have been prevented had it not been for widespread inaction and stigmatization. As HIV rates of infection soared in some countries, and larger portions of society became directly affected, there was no longer any doubt that the pandemic was a disaster in its own right.

The response to HIV in Botswana included the nationwide anti-retroviral therapy via the Masa (Setswana for ‘new dawn’) programme. Stigma and discrimination against HIV-positive people are now largely in the past.

In recent years, an increasing number of people have voluntarily had themselves tested, realizing the advantages of treatment. But people who openly admit their infection tend to be the exception.

The huge success of this healthcare intervention has rendered support groups trying to address discrimination less relevant and most have dissolved; a space for those who still felt discriminated against has been lost.

Indigenous knowledge is often displayed as false or mythical. This chapter is not promoting traditional medicine, but different expressions of health-related practice do coexist and sometimes collide; as many people believe in traditional medicine, it would be wrong not to work with it.

On AIDS-related public health action, many healers have felt patronized and forced into a parallel realm. Messages delivered by public health agents may no longer reach healers and their clients, patients may be excluded from biomedical treatment, and traditional healers’ approaches and therapy concepts may go unnoticed.

Even when there is no obvious clash, culture remains an important factor in public health. The degree to which HIV-infected people follow medical advice is crucial and it is of paramount importance to monitor adherence closely.

Botswana’s Masa scheme tries to secure adherence through an array of measures. Adherence must be interpreted both as biomedically mandatory and as a cultural process to be considered.

Empathy and cultural sensitivity seem to vanish at the higher administrative levels of intervening institutions engaged in disaster risk reduction, and in political and economic contexts. Decisions are made on the basis of fixed agendas and goals, mandatory for all employees to follow, and governed by the dynamics of huge administrations.

Successful approaches in times of disasters are often those that build on existing systems rather than import personnel. It is obvious that giving local health workers a voice in their organizations is essential, as is involving people directly affected by health threats.

Diverging interpretations of what constitutes health and healing may lead to the most vulnerable missing out. The 2008 World Health Report highlighted the importance of primary healthcare commitments, originally laid down in the Alma Ata Declaration in 1978. What can institutions learn?

Health issues are linked to everyday life and cultures as expressions of practices. Not all public health actions will be accepted willingly if they contradict long-standing interpretations.

Cultures also exist within public health institutions. Competence at grass-roots level must transfer to higher levels.

Cultural traits that may determine what actually constitutes a risk or a disaster should be reflected upon.

Many of the social determinants of health identified in the HIV/AIDS example and linked to culture and its implications for public health action are included in the WHO comprehensive model: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (and is deeply embedded in culture).

Local ownership of public health action can be increased through outreach by community health workers; there is no doubt about their potential to understand clients’ language and cultures, to deliver understandable messages.

Healthcare intervention is still largely constructed according to Western or Northern norms and practices. In disasters, mental stresses, such as a feelings of loss or grief, are too easily turned into pathological disorders.

It is not sufficient simply to recognize the existence of other concepts of healing and care. A dualistic notion of modern versus traditional hampers public health success if these concepts remain unconnected, and traditional healers play a crucial role in linking the two. Medical pluralism applies where people’s life experiences are in transition and different health concepts coexist.

Indigenous healthcare systems sometimes involve harmful practices.

Therapeutic pedagogy, psychopathology and palliative medicine are examples where the natural sciences have opened up to life beyond the rationality of maths, chemistry and physics. Such rationality is most obvious in the discussion about biosecurity, which is increasingly being linked to health systems - a discussion that, with the threat of global infectious diseases perceived to be increasing, turned into a debate on international human security. Hazard scenarios are taken as a legitimization for prioritizing protection against pathogens over developing culturally sensitive public healthcare.

Public health schemes are often based on rationales that prioritize biomedical approaches and efficiency. But questions of health and healing reach deeply into personal experience in that they touch on suffering, including the death of relatives and friends and the need to confront one’s own mortality. This extends into the realm of emotions, mental well-being, beliefs and collective and private assumptions.

Here questions arise that cannot be answered conclusively on a scientific basis alone - philosophical, religious or spiritual explanations are needed. It is, therefore, a requirement in public health action to:

Understand cultures as a mesh of practices interacting, and sometimes competing, with each other.

Acknowledge that public health agencies are engaged in very different cultural framings at different scales.

Take into account that organizations have their own internal communication and decision cultures.

Self-reflective, culturally sensitive public health that incorporates these complexities can make a difference in ensuring that basic healthcare and long-term disaster management, such as tackling HIV/AIDS, become more sustainable.