"Those on the
Major Herbert C.
Rader, MD, FACS, Medical Advisor, The Salvation Army
Tuesday, November 10, 1998, 2:15 p.m., Hyatt Regency Hotel, Atlanta
AIDS is like a
lens bringing critical issues into focus, including the inscrutable
complexities of human sexuality, motivation and behavior, the shameful
economic disparities and xenophobic prejudices that exist in society,
and the obligations of those with resources to share equitably and even
sacrificially with those who are in great need.
decimating many African nations, and ravaging the capital cities of
Southeast Asia, devastating the infrastructure and destroying the gains
of development programs. AIDS is also rampaging through our inner
cities, straining the health systems of the West. In the midst of this
suffering and loss, we are being called not only to awareness, sympathy
and token responses, but also to serious consideration of our
obligations as the people of God.
For more than a
decade The Salvation Army has been responding to the challenge of AIDS.
Our hospitals in India, Africa and Indonesia that have always focused on
the health care needs of the poor have been encouraged to develop
strategies to serve the complex needs of those affected by HIV/AIDS. The
Army's Booth Memorial Medical Center, now part of the New York
Presbyterian Healthcare Network, was the first AIDS-designated center in
In its preaching,
policies and programs, the Army has attempted to promote and demonstrate
unconditional caring for those affected by HIV/AIDS, - including the
invisible, voiceless, forgotten people on the margins. Its community
counseling program in Zambia has attracted international attention. Its
international program facilitation team has presented its work at each
of the International AIDS conferences. The Army's first international
AIDS consultation was convened in San Francisco in connection with the
International AIDS Conference in 1988.
commission - Great commandment
For 130 years we
have attempted to bring social action and proclamation of the gospel
together in integrated ministry, to fulfill both the great commission
and the great commandment in practical and balanced ways. While
government and the scientific community have focused largely on
understanding transmission, prevention and therapy in the context of
particular social groups, we have also tried to maintain an
international perspective, and a concern for those individuals who may
be missed by these programs.
People on the
margins - the plight of the poor
People are not
always marginalized because they have AIDS; some have AIDS because they
are marginalized. In many parts of the world, desperate adults, often
women and runaway children have been trapped in lifestyles and behaviors
that have placed them in harm's way.
director of Salvation Army social services in Hartford, has studied the
problems of male and female prostitutes. His findings: 82 % of
prostitutes were raped before age 16; all were raped at some time in
their lives, 49 % by a family member. 62 % were battered as children,
all were battered at some time; 93 % were runaways before becoming
Of 1. 2 million
runaways nationwide, 35 % leave home because of incest, and 53 % because
of physical abuse. As many as 1.6 n-million children may be working the
streets across the country. (Hartford Courant, Psychology Today)
John Foley has
developed counseling and support programs for women who will not leave
the lifestyle, and a five-year structured program for those attempting
to enter mainstream society. For both groups, AIDS education, often
using peer counselors, is provided, and for those with HIV/AIDS,
emotional and material support, child care and placement and spiritual
counseling in a context of loving acceptance is provided.
We have been
working with abused and exploited women, and women and children at risk,
since 1886. Finding alternatives has been the challenge. It is a long
journey for the woman who has experienced nothing but abuse and
exploitation, but the Army has learned to establish a new environment of
loving acceptance and coordinated care for those who will accept it.
Not hard to
find, but hard to reach
marginalized individuals are everywhere, sometimes in visible clusters:
the urban poor, the illiterate street kids sinking in the quicksand of
drugs, male and female sex workers; but often in close proximity to
affluent neighbors: the alienated, lonely, abandoned, forgotten, victims
of domestic violence, neglected babies and abused runaways.
Young, poor women
are being infected with HIV at a higher rate than male counterparts,
according to the CDC (August 27, 1998). The rates are also higher among
minority groups and the poor. "We are continuing to see that the face of
the epidemic is changing to populations that are more economically
disadvantaged and difficult to reach populations." (George Lamp,
director of the AIDS research program for the University of California)
opportunity and obligation.
A crisis for the
Such people are
all around us, and are generally closer to, and more likely to be
reached by, a church than a medical facility. Many voices are informing
us all that this is not a medical problem that can be solved with
medical discovery and intervention, but a complex social issue that will
require community participation at many levels, and particularly the
involvement of congregations.
While the church
may not have the resources of government, we are already deeply rooted
in areas of greatest need, we have a tradition and mandate to care for
the neglected and outcaste, we are discovering that we have the
expertise, facilities, access and rapport, credibility to facilitate
behavior change, and we have messages of hope both for those who are
making critical lifestyle choices and for those who are dying of AIDS.
benefit from medical advances?
In any event,
will medical advances actually benefit the masses of people in the
world? Although advances in therapy have slowed the death rate in the
U.S., 16,000 new HIV infections occurred every day in 1997 (5.8 million
new infections and 2.3 million deaths). 90% of the new infections are
occurring in developing countries. 30.6 million people are currently
living with HIV/AIDS: 860,000 in North America, 20.8 million in Africa,
6 million in Southeast Asia and India. (UNAIDS)
And the children:
1. 1 million under age 15 were living with HIV/AIDS at the end of 1997,
and 8.2 million were orphaned by AIDS through 1997. While the number of
deaths is declining in some areas, the number of new cases continues to
rise. AIDS has risen to the number four spot in the list of causes of
deaths, ahead of Malaria and just behind Tuberculosis. (UNAIDS)
of 'scientific' solutions
In a world where
children die of malnutrition, infant diarrhea and measles, and adults
still succumb to malaria and tuberculosis, expensive drugs will not stop
an epidemic among individuals who are infected because poverty forced
them to put themselves at risk.
The Joint UN
Programme on HIV/AIDS (UNAIDS) is working toward greater access, but we
know that drugs, and vaccines when they are eventually developed, will
never reach the millions in Africa, India and Asia that can not even
combination therapy for the infected population would cost 150 %, 244 %
and 264 % of the gross national product respectively for Suriname,
Honduras and Guyana (Montaner, J.S.G., et al, JAMA, April 22/29, 1998,
vol. 279, No 16, page 1264)
No cause for
The 12' World
AIDS Conference reports corrected the euphoria resulting from declining
death rates in patients on highly active retroviral therapy, including
protease inhibitors. "The virus remains, and ultimately it wins.
" (Stephenson, J., JAMA, August 19, 1998, vol. 280, No 7, pages
587-590). Associated epidemics, like tuberculosis, hepatitis B,
syphilis, gonorrhea, herpes, etc., have created their own problems. If
churches do not enter the fray to catalyze change and to bring hope,
many more will be lost.
The Army has
learned to be both a lighthouse and a lifeboat organization. We can not
change the "manufacturer's instructions," with respect to the immutable
rules for healthy living, nor can we move the lighthouse to accommodate
someone's desire to sail near the rocks. But we understand that our role
is not to shout from the shore, but to push out into the dangerous
waters, to come alongside with help, and to rescue those who are
foundering by all available means.
Noland, who is responsible for Army operations for the northeastern
states of the U.S., said recently: "I want every human being to be
treated with equality ... with respect ... with compassion. I don't want
any human being to be marginalized. "
share - transferable concepts
Bassett reports that the Army in Cincinnati organized a camp experience
for a variety of family units, including children, during the summer of
1998. At least one person in each family had HIV/AIDS, but no one
knew which ones. A staff of 30 provided a full camping experience for
these individuals who were referred by professional AIDS service
organizations. It was a religious event, but all worship was voluntary.
All camp facilities, including the pool, were available.
the Army's social service secretary for New Jersey, has developed a
respite camp for grandparents as an opportunity for inter-generational
camping, bringing children and their sometimes elderly care givers
together in a beautiful setting. During the year this experience
provides a point of entry into communities to reach others before they
The Army in
Schenectady has street outreach vans designed to locate runaways,
vulnerable and exploited young people, and to offer alternatives. The
strategy in Albany, Syracuse, Rochester and Buffalo is to get close to
those on the margins of society and to establish rapport and
relationships of trust, with a view to broadening horizons and
motivating behavior change.
the Army is providing day care and shelters for IV drug users migrating
from the tough streets of New York City. Runaways are getting younger
and younger. Jamestown and Elmira have domestic violence shelters for
women fleeing abusive relationships. HIV testing is always recommended.
AIDS services are provided as required.
facilities - re-channeling resources
In general, we
have integrated HIV/AIDS programs into existing ministries. An example
is the Adult Rehabilitation Program, a residential long-term program for
substance abusers with accommodation for approximately 11,000 young men
and women in centers across the United States. The Calgary AIDS hospice
is an important response, and represents an adaptation of an existing
facility to accommodate a new social need. The home-based hospice
program in Lancaster, PA, is another model that was developed in
consultation with the community.
In many locations
we have the advantage of a special relationship developed through a long
history of involvement in a particular community. Nevertheless, senior
social service consultants in North America now confess to a 'provider
mentality,' and failure sometimes to learn how to tap and use the wisdom
of those we serve. There is often fragmentation of the social services
provided by professionals from the caring ministries of the
issue of the Journal of AIDS and Human Retro virology reported
that traditional HIV-prevention programs are not enough to prevent the
spread of the virus among the poor. "We've got to be creative in getting
to them," said Linda Valleroy, a CDC epidemiologist and author of the
We need to find
entry points into communities, and caring for a patient with AIDS often
provides such a point of contact. We need to be present in the
community, helping them to identify their own leadership and to mobilize
their own resources and to develop their own solutions.
created an unprecedented impetus for collaboration among disparate
organizations, and unparalleled opportunities for entry into
communities. But participation in the life of communities requires new
ways of working, including team building, program to program sharing of
experience, and facilitation of local initiatives to foster sustained
We maintain that
prevention messages, including personal responsibility and
accountability within community, investment in the future and abstinence
from sex and drugs, in the context of life skills education, and
supported by mentoring and assistance to reach life goals, can make a
positive contribution to the well being of our young people. The
challenge remains to build relationships of trust that will provide
opportunities for influencing behavior change.
alongside to build capacity
Obviously, from a
global perspective, the medical approach will not work, and solutions
for prevention, care, for owning the problem and for owning the future,
must come from within communities.
approach of community counseling, facilitating community participation,
working alongside people to build capacity and to encourage change of
attitude and behavior, and to conceive and implement actions, began in
Zambia, but the concepts are transferable to other parts of the world,
and even to the west.
Based on our
experience with AIDS ministries in 100 countries, we offer to this
convocation and to the Body of Christ the affirmation and the challenge
that the Father of the orphan and widow, of the poor and the powerless,
is present and at work everywhere.
We have learned
that the courageous, resilient and resourceful peoples on the margins,
who have been left out, or put out, do not need our money as much as our
love; they do not need our imposed solutions to their problems, as much
as our assistance to discover their own answers.
It is often
thought that the urgency of the problem precludes reflection and the
slow processes of building relationships and capacity within communities
affected by AIDS. In fact, we are discovering that the opposite is true.
Only through a team approach to community counseling and gradually
building a capacity to hope, to believe that change is possible, to own
a future, to develop a joint approach to problem solving, can sustained
We are on a new
path that attempts to bring people together to find the solutions that
arise out of being together, of belonging, of working together toward
common goals. We are stepping away from the path of seeing individuals
in isolation, of applying "solutions" to "problems." A fortunate irony
is that HIV/AIDS, the crisis that can destroy relationships and bring
shame and despair, has been a remarkable entry point and impetus to new
approaches that are building relationships, promoting reconciliation and
Focus on the
In the past most
of us have tended to look at the 'emptiness' in the glass, to conduct a
'needs analysis,' and to design an intervention, including an infusion
of resources and expertise from the outside to solve a 'problem.' We are
learning to look at the 'assets' in every community, and to come
alongside those in community through facilities and programs already in
place, and through entry points created by the pandemic.
A breakthrough in
our approach has been the development of program facilitation and
community counseling teams that come alongside those living in the
context of H11V/A1DS to facilitate locally relevant and sustainable
approaches to change.
The new approach
focuses on strengths (like the extended family in Africa), rather than
weaknesses, and strives to build additional capacity for change (like
the modification of "ritual cleansing"), care and hope. This approach in
the developing world is consistent with the important work of McKnight,
Kretzmann and Benson in the United States.
Resources Within Communities
A team of
Salvationists, has used this way of working in the context of HIV/AIDS
to establish programs in forty very needy parts of the world, where the
prevalence of HIV is high and growing, and medical resources are scarce.
People are discovering that they themselves are the most important
resources, that they have capacity to learn, to change their attitudes,
their behaviors and their situation.
participation are words that have special meaning to our programme
facilitation team as they gather government and community leaders of all
backgrounds to discuss common problems and to inventory and mobilize
local resources. Solutions arise from the wisdom and strengths of the
people, and are not imposed as social policies or public health
New Ways of
takes us to the street in Buenos Aires, in Hartford, in Bombay. Runaway
and throwaway children must have an alternative to begging, stealing and
selling themselves, and commercial sex workers must have an alternative
to their debasing strategy for survival. Working with these groups
requires an entry point that may be a person with AIDS, for whom home
visits and care are taking place.
In Bangladesh we
learned that barriers to developing community capacity include
self-importance, unwillingness to listen or learn and a paternalistic
task orientation. Effectiveness in their setting requires developing
relationships, good communication, caring for a total person, helping
people to solve their own problems. Working alongside people requires
that we respect and value them. As one team member observed, "teachers"
must become "facilitators."
the Army's strategy of Integrated AIDS Management has attracted wide
attention, and program leaders have been invited to participate in the
National AIDS committee as a resource organization, the first
field-based NGO to receive such an invitation. During meetings with
community leaders the official approach has changed from punishment of
commercial sex workers to promoting behavior change among their
customers, including the leaders' own children.
Over the past ten
years programme facilitation teams have worked in Bangladesh, Rio de
Janeiro in Brazil, Ghana, Haiti, Mizoram, Calcutta, Bombay and elsewhere
in India, The Marshall Islands, Pakistan, Papua New Guinea, the
Philippines, Soweto and Capetown in South Africa, Sri Lanka, Uganda,
Zaire and Tshelenyemba in Zimbabwe and elsewhere.
commercial sex workers in two brothel projects are changing attitudes
and behaviors, and team members are also changing as they learn along
with those who are struggling with the questions of whether change is
necessary and possible, and whether alternatives can be developed, and
whether the result will be worth the effort.
Petersburg, a team is winning the trust of HIV-infected drug users to
provide services to them and their families. At the same time, young
people are being trained to reach school children and college students
at special summer camps.
Haiti, more than 3,000 orphans have been registered by the Salvation
Army, but caring for them has opened doors into the community allowing
teams to make home visits to promote awareness of the means of HIV
transmission and to encourage behavior change. At Ethembeni "Place of
Hope" in South Africa, infants and children are gathered up and cared
The hardest thing
to accept from inter-regional consultations was the notion that the
developing world is comparable to the west or has anything to teach us.
In fact, it has turned out that we have had to learn from India and
Africa many of the concepts and approaches that are necessary to bring
about sustained behavior change in any setting.
program exchange has been a key 'way of working.' It is of interest that
when the Army began to plan for a residential hospice for individuals
dying of AIDS in Lancaster County, a team led by Ian Campbell and made
up of persons with experience in the developing world, met with the
community to discuss needs and solutions. The result was a home-based
program which looks more like a Zambian approach than a typical North
Lessons from a
street program in Canada include: "inclusiveness is a requirement;
diversity is a resource and not an impediment." Work within a community
must be inclusive and involve genuine participation that empowers the
people to define their own reality, and assume their own responsibility.
A belief in
the capacity to change
ghettoes and barrios of the world, the boys of Buenos Aires, the street
walkers of European cities and the women of Africa, infected by
wandering husbands, have all been areas of special focus. Prevention
education is provided and trusted counselors begin to instill a belief
in the capacity to change and create a more hopeful future. As capacity
grows, ideas about alternate revenue generating activities emerge and
are implemented. Plans which arise from within the community foster the
development of leadership and are sustainable.
Care is a
Ways of working
developed by these field teams have been shared program to program with
the result that mutual learning has occurred, and many concepts have
been found to be transferable from South to North and East to West. The
team has discovered that certain core concepts are transferable, even if
specific local programs are not. Among them are "care" understood as
journeying together rather than providing or administering care.
belonging in healthy relationships rather than arbitrary or accidental
geographic or organizational grouping. "Change" relates to the
transformation that comes from within rather than change dictated and
directed from outside.
We are beginning
to see in the pattern of the Word who became flesh to dwell among us,
and the Holy Spirit, the paraclete who comes alongside to enlighten,
encourage and empower, the model for our participation in community to
encourage change toward the future we all hope for.
participation in the life of community, and facilitation of a change
process is intended to build the capacity to identify the giftedness,
skills and wisdom of the community, to work together across traditional
boundaries, solve problems through understanding, compromise and
consensus building, to generate resources and to implement internally
We have been
saying for some time that faith congregations and not medical centers
must necessarily become healing communities out of which teams could be
deployed to the homes of those affected by HIV/AIDS as comforters,
listeners, counselors, facilitators. Communities are mobilizing in
unexpected and unprecedented ways to maintain hope, accept
responsibility, and develop locally appropriate and sustainable
responses. Faith communities have played a critical role.
New life goals
We are not
indifferent to the consequences of various lifestyle choices, but our
approach is always to begin where people are and to provide care through
participation with them in the realities of their situation. For
individuals in danger, such an approach must sometimes include throwing
out a lifeline, like a needle exchange program in Melbourne.
Accompanying people on their journey enables them to make better choices
as they move forward.
are not necessarily effective just because they are politically correct.
We waste no energy on condemnation of those affected, but we are not
reluctant to point out the relationship between particular behaviors and
infection, and the importance of avoiding those behaviors.
Love in the
face of fear, Hope in the midst of despair
Our faith in the
sufficiency of Jesus Christ motivates and sustains us, and it brings a
message of unconditional love and transforming grace to those we serve.
Love amid fear, joy amid suffering, hope amid despair are being
experienced even by Zambian households where the fresh graves of young
people surround village huts. -Mothers and fathers dying of AIDS are
comforted by other family members who accompany them with singing and
prayer as they cross into eternal life.
mercies, God of peace, You have sent me, as my Lord was sent, into a
world sick with hate. He proclaimed peace. He put hostility to death
through the cross. He created in Himself one new humanity. I too would
dare to be a peacemaker. Forgive me for my indifference. "
"(I have not)
embraced the larger underclass of strangers. the mentally infirm, the
afflicted, the incarcerated, the malefactor against my views and tastes,
those I tend to distrust, to demonize to disdain or ignore. Father of
mercies, faltering and weak my labor has been. Have mercy. " (Lyell
"Here at the
cross in this sacred hour, here at the source of reviving power,
helpless indeed, I come with my need; Lord, for Thy service, fit me I
in Transition - Care as a Catalyst to Health, Healing and Integrated
International Health Programme Consultant, London, March, 1998.
2. Loss, Hope
and Faith Through a Community Development Approach to H1V/AIDS - The
Foundation to an
Expanded Response, Ian Campbell, The Salvation Army, 1998.
Counseling, A Handbook for Facilitating Care and Change -- an
HIV/AIDS, The Salvation Army, ed. by Alison Rader, London, Revised,
Communities from the Inside Out, John McKnight, and John Kretzmann,
University), Evanston: ACTA Publications, 1993.
5. What Kids
Need to Succeed, Peter Benson, Judy Galbraith, and Pam Espeland,
6. A Prayer of
Turning, Lyell Rader, The War Cry, October 3, 1998, page 16.