This article was downloaded by: [Deakin University Library] On: 13 March 2015, At: 08:49 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Integrated AIDS management a
Ian D. Campbell & Alison D. Rader
b
a
Medical Adviser, The Salvation Army, International Headquarters , 101 Queen Victoria Street, London, EC4P 4EP, UK b
Project Manager for AIDS, The Salvation Army, Chikankata Hospital , Private Bag 52, Mazabuka, Zambia Published online: 25 Sep 2007.
To cite this article: Ian D. Campbell & Alison D. Rader (1990) Integrated AIDS management, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:2, 183-188, DOI: 10.1080/09540129008257729 To link to this article: http://dx.doi.org/10.1080/09540129008257729
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 2, NO. 2,1990
183
IN PRACTICE
Integrated AIDS management* IAND. CAMPBELL’ & ALISON D. RADER*
Downloaded by [Deakin University Library] at 08:49 13 March 2015
‘MedicalAdviser, The Salvation Army, Intentational Headquarters, I01 Queen Victoria Street, London EC4P 4EP, UK and =ProjectManager for AIDS, The Salvation Army, Chikunkata Hospital, Private Bag 52, Mazabuka, Zambia
Abstract AIDS is a multi-disciplinary problem, but also a multi-disciplinaty opportunity, given the capacity of individuals, groups and osganizations w integrate talents and resources. The impact of AIDS in east, southern and central Africa i s discussed in general terms to a m m the question. “Why integrate?” Ways in which integration is expressed are discussed, including integration within the definition of AIDS management, integration d i n programs, and between team members, between the community and the hospital, and from field programs to Ministries of Health, donor organizations and the World Health Organization. Issues in integration at the field level, including management models, the concept of teams, and consensu~on major goals, are discussed, and comment is made on the key integrative theme of families and communities.
Introduction It has been said that management is concerned with getting things done, whereas leadershp is concerned with h m and what things get done. Both concepts need to be addressed in relation to integration. AIDS is a multi-disciplinary problem, but also a multi-disciplinary opportunity, given the capacity of individuals to integrate talents, to sublimate personal objectives into the greater good, to be leaders as well as managers Integration has to do with bringing together. It involves a plan to share information, to glean practical directions for the future, and an attitude of relying on others, whilst not totally depending on others. There is a spirit of mutual dependance, from different countries and from different parts of the world, with a commitment to international interdependence which in essence is the key attitude which leads to genuine integration of ideas, of objectives, of plans of management by people of widely diverse backgrounds.
W h y integrate-what makes AIDS special? The past 6 years has been characterized by the spread of the disease in all continents of the world. The key words have been ‘epidemiology’ and ‘survey’, rather than ‘management’. *Introductory address to a Conference of field workers in Nairobi on 19-25 May 1988.
184 1.
CONFERENCE ADDRESS
What Do We Know?
Downloaded by [Deakin University Library] at 08:49 13 March 2015
(i) The disease is likely to be fatal in close to 100 percent of HIV positive people. Whereas 2 or 3 years ago, people talked with relative confidence about a 10-30 percent illness development rate, there is now little predictive comment. No-one knows, but it is closer to 100 percent than before. (ii) There is no cure. (iii) There is no vaccine. (iv) There is no clear d e h t i o n of management principles in a comprehensive sense, applicable to all communities. (v) One piece of positive information is that prevention is certain if sustained behavior change occurs in individuals and communities.
2. AIDSinAfrrca One man, a retired civil servant, presented 18 months ago with &arrhoea and weight loss over a period of 8 months. He was found to be seropositive. He mentioned at the time he was informed he was HIV+ that his son was also in the hospital. His son was aged 12, had generalized lymphadenopathy, and had a history of blood transfusion 5 years previously. The blood had been provided by his father. The man’s two wives were contacted and agreed to having blood taken for HIV. Both were positive. The man and one wife have both died. The son has been intermittently unwell. His two daughters both have AIDS, from separate SOuTCeS.
In one continent at least, we note the following:(1) AIDS is a family disease, particulary in Africa-not just in terms of infection of mother and father and children, but it is a family disease in terms of stress in psychological, economic and social realms. It is no longer relevant to talk just of high risk behaviours or hgh risk groups. If one is alive in the average Central or East African community then one is at risk, when one speaks in the context of 5, and 10% prevalence rates and greater amongst the sexually active population and amongst children under 5 years of age. Every disease affects the family as a whole, and it can be expected that AIDS will manifest itself likewise but accentuated in its family impact in Africa by the nature of ‘extended family’ in that continent, and by the unique pattern of penetration of the HIV virus in families and communities. Not only prostitutes, those with STD, young men looking for a good time, but fathers, mothers, grandfathers, school goers, church goers, and children, are affected. (2) Africa and AIDS reveals dimensions of suffering not previously experienced in modem times. Whatever may have been experienced in past epidemics in previous centuries is not really relevant to the present day. Present day suffering demands a present day response, with all the known rules of management. The suffering is protracted, and, unlike cancers, AIDS is less amenable to current palliative therapies. (3) In Africa AIDS challenges individuals, families and whole communities to identify the nature of personal responsibility, and, in doing that, the nature of personal identity. Communities are challenged into the realization of the indivisible link between personal and public responsibilities. It is an enormous problem requiring courageous answers directed toward physical survival of communities, such as the comment from Chief Mweenda, of the area near Chikankata Hospital, after a community counselling intervention, and after a vote of headmen. “It is now the law of this land that sexual intercourse by means of ritual cleansing will no longer occur”. Communities will be asking “How should we express ourselves sexually?”, “How badly do we want children?”. “Who are we?”
INTEGRATED AIDS MANAGEMENT
185
Downloaded by [Deakin University Library] at 08:49 13 March 2015
3. Global AIDS, African solutions Is the African pattern to be repeated in other continents? From what is understood of the disease, it could be, and that is more than enough reason for the international community to be alerted not just to the special dimension of AIDS in Africa, but to the potentially special dimensions of AIDS in comparison to the nature of other diseases in the rest of the world. Other diseases e.g. diarrheal disease, tuberculosis, leprosy, cancers, to be consistent, demand a concerned, concerted response, and to the best of our ability, we mount that kind of response in hospitals and within home care settings. It is true, however, that the world has limited resources, and we must respond to the priority of the day. At the present time, no other disease of which we know, either sexually transmitted or any other terminal disease has the same community penetrance, or challenges the basic human identity of individuals and communities, as does AIDS. Figures may speak to some people, but in the end, people speak to people. It is probably the case, unfortunately, that the world as a whole will not be alerted to the challenge of AIDS until it is felt personally by most families and individuals, because someone they know is ill or dead, as is happening now in many parts of Central and Eastern Africa. The African response can be a source of hope internationally. The international community is obligated to observe and to facilitate the African response, which can in all probability provide answers for the rest of the world, through demonstrating skills in comprehensive and culturally appropriate management which integrates people. Africa contains the pattern on which the ‘global village’ can be established. How is integration expressed? Integration is expressed in at least four senses:(1) An integrated management approach to each of the following disciplines: (i) Clinical/nursing/laboratory, (ii) Education, (iii) Counselling, (iv) Pastoral Care, (v) Administration. (2) A sense of integration between hospital based disciplines and community based disciplines of the above kinds-for example, hospital-based counselling is essential to adequate preparation for the first team visit in the home setting. By the time the team arrives, the patient and family are ready to welcome the team, and many potential barriers have been bypassed before they have become a problem. (3) Integration between the field (both government and non-government hospitals and health centers) and people at policy making level, of government, donor organizations, and the World Health Organization. Zambia is one country of the region which has established formal dialogue of this kind. At the end of 1988, formal agreement was reached with the Ministry of Health, WHO, the Churches Medical Association of Zambia (CMAZ), and NORAD, that funds would be released from the WHO medium term plan to fund, potentially, all 86 church administered health institutions in AIDS care and prevention programs. The money has been released and distributed. CMAZ has membershp in the AIDS Management Committee, the main implementing arm of the national AIDS Surveillance Committee. A church administered hospital is represented on the national counselling committee, not specifically because of CMAZ but, more importantly, because of the fact that the hospital represents field work, and the Ministry of Health along with WHO have seen the value of field participation, whether government or non-government, at senior policy making level. (4) A fourth, more subtle, process of integration is that happening within the AIDS
Downloaded by [Deakin University Library] at 08:49 13 March 2015
186
CONFERENCE ADDRESS
care and prevention department or unit at district hospital level, and between departments of that same hospital. Integration of concepts between departments can be promoted by encouraging pan time attachment of staff from other departments to the AIDS care and prevention department. Integration between team members of the AIDS department can be fachtated by promoting leadership development skills in the whole team, to the extent that team leadership can be shared, depending on who is available on the day of the activity, e.g. a m p of the home-based care and prevention team. ( 5 ) Integration is expressed most effectively by a joint recognition by all concerned people of the following points: (i) We are explorers, yet we need to act. (ii) Whilst we act, we do not have all the answers. We learn by doing. Our minds are open to further enlightenment. We are prepared to listen, to each other, but more importantly to the so called ‘ordinary’ people. Their lives are at stake, and they have the answers for their own survival.
Issues in integration at the field level-some areas for exploration
Management models With respect to structures for AIDS management at field level, established health management strategy should be utilized, though new programmes, skills, and management teams may need to be developed. The PHC principle, since Alma Ata of 1978, has been misunderstood in at least two senses: the first is that PHC is the stirring of community initiative. The second is that management structures are necessary for effective PHC implementation, but this obvious and most basic of steps has been often overlooked. AIDS care and control is dependent on the same two factors. Practical administration is given priority in order to help think through the need for organized, structured responses, whch use established health care strategies such as the PHC principle to get the job done. Admistrative structures are necessary to allow freedom to develop specific skills, to cover the volume of work required, and to allow other departments to do their job. All units and departments of a district hospital, and indeed of a city teaching hospital, need to be responsible for education in the form of information transmission. Cooperative liaison, or non-supervisory horizontal links, need to develop between other departments and AIDS units. There need be no conflict between ‘vertical’ and ‘horizontal’. It is necessary to recognize, however, that AIDS ‘management’ is defined as a comprehensive multi-disciplinary integrated approach to the patient and the community. Administration is listed last in the definition but it is certainly not least.
Team work Team work sounds simple, and essentially it is, but it is the most profound factor in the development of effective AIDS care and prevention programmes. In AIDS care and prevention, team work accelerates programme development and personal development of team members. In terms of clinical care, education, counselling, pastoral care, and administrative aspects of management, personnel can interchange the leadership role and can interchange other roles, depending on their background professional qualification, e.g. if a person is to take a clinical role he or she could be a clinical officer, a nurse, or a doctor, and furthermore
Downloaded by [Deakin University Library] at 08:49 13 March 2015
INTEGRATED AIDS MANAGEMENT
187
he or she can build up slulls in the other disciplines, e.g. counselling. Counselling effectiveness at the individual, family and community levels is enhanced by a team approach. Teams reduce stress. It is a natural process after a home visit or an intense ward counselling session to wish to reflect and debrief. The existence of a team provides for spontaneous emotional ventilation. W h o cares for the carers? The carers care for each other if a team exists. The lunch break during the day of home visits provides physical, mental, emotional and professional refreshment. For some teams the essential element to success is spiritual commitment, and this can be constructively developed through creating time for meditation and staff development studies, away from the institution. The time spent by the team not working is as just important as the time spent working. A team concept in AIDS care and prevention speaks of a network within a network-the network of the AIDS care and prevention team within the expanded community network, which is in itself a team, and which is the inherent strength of African communities. The benefits of team work are many-chiefly, the promotion of inclusion and burden sharing compared with isolation. The establishment of teams promotes transfer of team concepts within the community so that the team becomes part of the community and the community becomes part of the team.
Consensus on major go&
Current debate on many issues within AIDS care and prevention reveals the inner turmoil of individuals, health workers, policy makers and program planners. Shall we pre-test counsel? What test is best? What about condoms? We have limited money, but are we obligated to accept international agendas, many of which are inappropriate to local culture. In the exploration there may be differences, and yet at the same time there may be a common commitment to permanent solutions. Beware the detours, the hidden agendas, sometimes European and sometimes local, but in all cases expressions of denial of long term responsibility, and of reality. One certain preventive strategy is sustained behaviour change with respect to patterns of sexual intercourse. If this is acknowledged positive constructive proposals and convictions on achieving behaviour change will emerge. Often workers have not seriously grasped the necessity of massive social mobilization directed toward this goal. Other subsidiary goals are sometimes mistaken for primary goals, e.g. information transmission, condom promotion. The answers to such personal and intimate challenges will come from the field. The policy makers need to hear it from the workers who need to hear the message from the people they serve. These people, in Africa, represent families and communities, which are still intact, if one looks hard enough, even in most cities. This is a national and a regional strength. The family is available and capable of sharing responsibility. It provides economic support and the capacity of the family to be the ‘responsibility unit’ is transferrable to other families. Health providers in many instances will have to be prepared to redefine their role, and their basic identity, if effective prevention is to be realized. The initiative needs to come from where the suffering is greatest, where patient contact is happening. If those who represent the field hold the reins of their own responsibility, and promote responsibility for care and prevention in families and the so called ‘ordinary people’, then the policy makers and the international organizations will become what they should really be, which is facilitators and appropriate resources for advice and for policy clarification.
188 CONFERENCE ADDRESS As we explore step by step, the practical challenges of programme implementation, and relates policy making to the needs of people, above all else, then some of the international debate will become muted, there will be less distraction, and there will be more progress.
Downloaded by [Deakin University Library] at 08:49 13 March 2015
Conclusion
Within the diversity, there has to be a commitment to integration. The key strategy is to find the community and provide the support needed for the community to work for itself. Let the community work for itself, and there is a future. That vision can be achieved by putting off the superficial, by recognizing that we are each team members, whatever our geographical location, and by recognizing that, although we may be widely scattered physically, we each have the opportunity to move into a confident response because we are committed to the context of integration. Sometimes the surprising fact is that it is only when we are pushed into urgent response, as in the case of AIDS, that we discover capacities as yet unutilized, and in so doing we grow, and move from paralysis to action, and from fear to hope.
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Integrated AIDS management a
Ian D. Campbell & Alison D. Rader
b
a
Medical Adviser, The Salvation Army, International Headquarters , 101 Queen Victoria Street, London, EC4P 4EP, UK b
Project Manager for AIDS, The Salvation Army, Chikankata Hospital , Private Bag 52, Mazabuka, Zambia Published online: 25 Sep 2007.
To cite this article: Ian D. Campbell & Alison D. Rader (1990) Integrated AIDS management, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:2, 183-188, DOI: 10.1080/09540129008257729 To link to this article: http://dx.doi.org/10.1080/09540129008257729
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 2, NO. 2,1990
183
IN PRACTICE
Integrated AIDS management* IAND. CAMPBELL’ & ALISON D. RADER*
Downloaded by [Deakin University Library] at 08:49 13 March 2015
‘MedicalAdviser, The Salvation Army, Intentational Headquarters, I01 Queen Victoria Street, London EC4P 4EP, UK and =ProjectManager for AIDS, The Salvation Army, Chikunkata Hospital, Private Bag 52, Mazabuka, Zambia
Abstract AIDS is a multi-disciplinary problem, but also a multi-disciplinaty opportunity, given the capacity of individuals, groups and osganizations w integrate talents and resources. The impact of AIDS in east, southern and central Africa i s discussed in general terms to a m m the question. “Why integrate?” Ways in which integration is expressed are discussed, including integration within the definition of AIDS management, integration d i n programs, and between team members, between the community and the hospital, and from field programs to Ministries of Health, donor organizations and the World Health Organization. Issues in integration at the field level, including management models, the concept of teams, and consensu~on major goals, are discussed, and comment is made on the key integrative theme of families and communities.
Introduction It has been said that management is concerned with getting things done, whereas leadershp is concerned with h m and what things get done. Both concepts need to be addressed in relation to integration. AIDS is a multi-disciplinary problem, but also a multi-disciplinary opportunity, given the capacity of individuals to integrate talents, to sublimate personal objectives into the greater good, to be leaders as well as managers Integration has to do with bringing together. It involves a plan to share information, to glean practical directions for the future, and an attitude of relying on others, whilst not totally depending on others. There is a spirit of mutual dependance, from different countries and from different parts of the world, with a commitment to international interdependence which in essence is the key attitude which leads to genuine integration of ideas, of objectives, of plans of management by people of widely diverse backgrounds.
W h y integrate-what makes AIDS special? The past 6 years has been characterized by the spread of the disease in all continents of the world. The key words have been ‘epidemiology’ and ‘survey’, rather than ‘management’. *Introductory address to a Conference of field workers in Nairobi on 19-25 May 1988.
184 1.
CONFERENCE ADDRESS
What Do We Know?
Downloaded by [Deakin University Library] at 08:49 13 March 2015
(i) The disease is likely to be fatal in close to 100 percent of HIV positive people. Whereas 2 or 3 years ago, people talked with relative confidence about a 10-30 percent illness development rate, there is now little predictive comment. No-one knows, but it is closer to 100 percent than before. (ii) There is no cure. (iii) There is no vaccine. (iv) There is no clear d e h t i o n of management principles in a comprehensive sense, applicable to all communities. (v) One piece of positive information is that prevention is certain if sustained behavior change occurs in individuals and communities.
2. AIDSinAfrrca One man, a retired civil servant, presented 18 months ago with &arrhoea and weight loss over a period of 8 months. He was found to be seropositive. He mentioned at the time he was informed he was HIV+ that his son was also in the hospital. His son was aged 12, had generalized lymphadenopathy, and had a history of blood transfusion 5 years previously. The blood had been provided by his father. The man’s two wives were contacted and agreed to having blood taken for HIV. Both were positive. The man and one wife have both died. The son has been intermittently unwell. His two daughters both have AIDS, from separate SOuTCeS.
In one continent at least, we note the following:(1) AIDS is a family disease, particulary in Africa-not just in terms of infection of mother and father and children, but it is a family disease in terms of stress in psychological, economic and social realms. It is no longer relevant to talk just of high risk behaviours or hgh risk groups. If one is alive in the average Central or East African community then one is at risk, when one speaks in the context of 5, and 10% prevalence rates and greater amongst the sexually active population and amongst children under 5 years of age. Every disease affects the family as a whole, and it can be expected that AIDS will manifest itself likewise but accentuated in its family impact in Africa by the nature of ‘extended family’ in that continent, and by the unique pattern of penetration of the HIV virus in families and communities. Not only prostitutes, those with STD, young men looking for a good time, but fathers, mothers, grandfathers, school goers, church goers, and children, are affected. (2) Africa and AIDS reveals dimensions of suffering not previously experienced in modem times. Whatever may have been experienced in past epidemics in previous centuries is not really relevant to the present day. Present day suffering demands a present day response, with all the known rules of management. The suffering is protracted, and, unlike cancers, AIDS is less amenable to current palliative therapies. (3) In Africa AIDS challenges individuals, families and whole communities to identify the nature of personal responsibility, and, in doing that, the nature of personal identity. Communities are challenged into the realization of the indivisible link between personal and public responsibilities. It is an enormous problem requiring courageous answers directed toward physical survival of communities, such as the comment from Chief Mweenda, of the area near Chikankata Hospital, after a community counselling intervention, and after a vote of headmen. “It is now the law of this land that sexual intercourse by means of ritual cleansing will no longer occur”. Communities will be asking “How should we express ourselves sexually?”, “How badly do we want children?”. “Who are we?”
INTEGRATED AIDS MANAGEMENT
185
Downloaded by [Deakin University Library] at 08:49 13 March 2015
3. Global AIDS, African solutions Is the African pattern to be repeated in other continents? From what is understood of the disease, it could be, and that is more than enough reason for the international community to be alerted not just to the special dimension of AIDS in Africa, but to the potentially special dimensions of AIDS in comparison to the nature of other diseases in the rest of the world. Other diseases e.g. diarrheal disease, tuberculosis, leprosy, cancers, to be consistent, demand a concerned, concerted response, and to the best of our ability, we mount that kind of response in hospitals and within home care settings. It is true, however, that the world has limited resources, and we must respond to the priority of the day. At the present time, no other disease of which we know, either sexually transmitted or any other terminal disease has the same community penetrance, or challenges the basic human identity of individuals and communities, as does AIDS. Figures may speak to some people, but in the end, people speak to people. It is probably the case, unfortunately, that the world as a whole will not be alerted to the challenge of AIDS until it is felt personally by most families and individuals, because someone they know is ill or dead, as is happening now in many parts of Central and Eastern Africa. The African response can be a source of hope internationally. The international community is obligated to observe and to facilitate the African response, which can in all probability provide answers for the rest of the world, through demonstrating skills in comprehensive and culturally appropriate management which integrates people. Africa contains the pattern on which the ‘global village’ can be established. How is integration expressed? Integration is expressed in at least four senses:(1) An integrated management approach to each of the following disciplines: (i) Clinical/nursing/laboratory, (ii) Education, (iii) Counselling, (iv) Pastoral Care, (v) Administration. (2) A sense of integration between hospital based disciplines and community based disciplines of the above kinds-for example, hospital-based counselling is essential to adequate preparation for the first team visit in the home setting. By the time the team arrives, the patient and family are ready to welcome the team, and many potential barriers have been bypassed before they have become a problem. (3) Integration between the field (both government and non-government hospitals and health centers) and people at policy making level, of government, donor organizations, and the World Health Organization. Zambia is one country of the region which has established formal dialogue of this kind. At the end of 1988, formal agreement was reached with the Ministry of Health, WHO, the Churches Medical Association of Zambia (CMAZ), and NORAD, that funds would be released from the WHO medium term plan to fund, potentially, all 86 church administered health institutions in AIDS care and prevention programs. The money has been released and distributed. CMAZ has membershp in the AIDS Management Committee, the main implementing arm of the national AIDS Surveillance Committee. A church administered hospital is represented on the national counselling committee, not specifically because of CMAZ but, more importantly, because of the fact that the hospital represents field work, and the Ministry of Health along with WHO have seen the value of field participation, whether government or non-government, at senior policy making level. (4) A fourth, more subtle, process of integration is that happening within the AIDS
Downloaded by [Deakin University Library] at 08:49 13 March 2015
186
CONFERENCE ADDRESS
care and prevention department or unit at district hospital level, and between departments of that same hospital. Integration of concepts between departments can be promoted by encouraging pan time attachment of staff from other departments to the AIDS care and prevention department. Integration between team members of the AIDS department can be fachtated by promoting leadership development skills in the whole team, to the extent that team leadership can be shared, depending on who is available on the day of the activity, e.g. a m p of the home-based care and prevention team. ( 5 ) Integration is expressed most effectively by a joint recognition by all concerned people of the following points: (i) We are explorers, yet we need to act. (ii) Whilst we act, we do not have all the answers. We learn by doing. Our minds are open to further enlightenment. We are prepared to listen, to each other, but more importantly to the so called ‘ordinary’ people. Their lives are at stake, and they have the answers for their own survival.
Issues in integration at the field level-some areas for exploration
Management models With respect to structures for AIDS management at field level, established health management strategy should be utilized, though new programmes, skills, and management teams may need to be developed. The PHC principle, since Alma Ata of 1978, has been misunderstood in at least two senses: the first is that PHC is the stirring of community initiative. The second is that management structures are necessary for effective PHC implementation, but this obvious and most basic of steps has been often overlooked. AIDS care and control is dependent on the same two factors. Practical administration is given priority in order to help think through the need for organized, structured responses, whch use established health care strategies such as the PHC principle to get the job done. Admistrative structures are necessary to allow freedom to develop specific skills, to cover the volume of work required, and to allow other departments to do their job. All units and departments of a district hospital, and indeed of a city teaching hospital, need to be responsible for education in the form of information transmission. Cooperative liaison, or non-supervisory horizontal links, need to develop between other departments and AIDS units. There need be no conflict between ‘vertical’ and ‘horizontal’. It is necessary to recognize, however, that AIDS ‘management’ is defined as a comprehensive multi-disciplinary integrated approach to the patient and the community. Administration is listed last in the definition but it is certainly not least.
Team work Team work sounds simple, and essentially it is, but it is the most profound factor in the development of effective AIDS care and prevention programmes. In AIDS care and prevention, team work accelerates programme development and personal development of team members. In terms of clinical care, education, counselling, pastoral care, and administrative aspects of management, personnel can interchange the leadership role and can interchange other roles, depending on their background professional qualification, e.g. if a person is to take a clinical role he or she could be a clinical officer, a nurse, or a doctor, and furthermore
Downloaded by [Deakin University Library] at 08:49 13 March 2015
INTEGRATED AIDS MANAGEMENT
187
he or she can build up slulls in the other disciplines, e.g. counselling. Counselling effectiveness at the individual, family and community levels is enhanced by a team approach. Teams reduce stress. It is a natural process after a home visit or an intense ward counselling session to wish to reflect and debrief. The existence of a team provides for spontaneous emotional ventilation. W h o cares for the carers? The carers care for each other if a team exists. The lunch break during the day of home visits provides physical, mental, emotional and professional refreshment. For some teams the essential element to success is spiritual commitment, and this can be constructively developed through creating time for meditation and staff development studies, away from the institution. The time spent by the team not working is as just important as the time spent working. A team concept in AIDS care and prevention speaks of a network within a network-the network of the AIDS care and prevention team within the expanded community network, which is in itself a team, and which is the inherent strength of African communities. The benefits of team work are many-chiefly, the promotion of inclusion and burden sharing compared with isolation. The establishment of teams promotes transfer of team concepts within the community so that the team becomes part of the community and the community becomes part of the team.
Consensus on major go&
Current debate on many issues within AIDS care and prevention reveals the inner turmoil of individuals, health workers, policy makers and program planners. Shall we pre-test counsel? What test is best? What about condoms? We have limited money, but are we obligated to accept international agendas, many of which are inappropriate to local culture. In the exploration there may be differences, and yet at the same time there may be a common commitment to permanent solutions. Beware the detours, the hidden agendas, sometimes European and sometimes local, but in all cases expressions of denial of long term responsibility, and of reality. One certain preventive strategy is sustained behaviour change with respect to patterns of sexual intercourse. If this is acknowledged positive constructive proposals and convictions on achieving behaviour change will emerge. Often workers have not seriously grasped the necessity of massive social mobilization directed toward this goal. Other subsidiary goals are sometimes mistaken for primary goals, e.g. information transmission, condom promotion. The answers to such personal and intimate challenges will come from the field. The policy makers need to hear it from the workers who need to hear the message from the people they serve. These people, in Africa, represent families and communities, which are still intact, if one looks hard enough, even in most cities. This is a national and a regional strength. The family is available and capable of sharing responsibility. It provides economic support and the capacity of the family to be the ‘responsibility unit’ is transferrable to other families. Health providers in many instances will have to be prepared to redefine their role, and their basic identity, if effective prevention is to be realized. The initiative needs to come from where the suffering is greatest, where patient contact is happening. If those who represent the field hold the reins of their own responsibility, and promote responsibility for care and prevention in families and the so called ‘ordinary people’, then the policy makers and the international organizations will become what they should really be, which is facilitators and appropriate resources for advice and for policy clarification.
188 CONFERENCE ADDRESS As we explore step by step, the practical challenges of programme implementation, and relates policy making to the needs of people, above all else, then some of the international debate will become muted, there will be less distraction, and there will be more progress.
Downloaded by [Deakin University Library] at 08:49 13 March 2015
Conclusion
Within the diversity, there has to be a commitment to integration. The key strategy is to find the community and provide the support needed for the community to work for itself. Let the community work for itself, and there is a future. That vision can be achieved by putting off the superficial, by recognizing that we are each team members, whatever our geographical location, and by recognizing that, although we may be widely scattered physically, we each have the opportunity to move into a confident response because we are committed to the context of integration. Sometimes the surprising fact is that it is only when we are pushed into urgent response, as in the case of AIDS, that we discover capacities as yet unutilized, and in so doing we grow, and move from paralysis to action, and from fear to hope.
