Symposium “Community Action for Health”: South Africa

The Community ist my University

Von Erika Sutter & Selina Maphorogo / CBM Christoffel Blindenmission (Schweiz) / DM - Echange et Mission

"When communities are striving to meet a certain objective they also gain self-reliance and human dignity, and this is permanent. This encourages them to continue to help themselves. Community development is a learning process. Each step that people take to reach a certain objective makes them able to do the next step better, which will improve the next project they undertake."

“The little town of Louis Trichardt, with its abundance of churches and shops, is the trading and social centre for the farmers in this north-eastern corner of South Africa. Leaving the town, you will find a road crossing the valley that leads to Elim Hospital, 25 kilometres to the south-east. It passes through thornbush country, with cattle ranches and occasional irrigated fields growing cash crops, mainly peanuts or maize. Here and there, a farmhouse can be seen in the distance.

Before reaching the Elim hospital on the hill, you pass by a large settlement. The round, grass roofed houses and a few rectangular buildings with corrugated iron roofs are tightly packed along the sides of the small sandy paths. This densely populated area is an abrupt change from the land of the White farmers, with its irrigated fields and sparse population. The soil is bare and sandy; goats are busy eating the scanty dry grass that grows between the scattered low thorny bushes. You have entered ‘African’ country – until recently a so called ‘Homeland’.

The Elim Care Group Project was initiated when I was head of the Eye Department of Elim Hospital, originally with the specific objective of reducing blindness. It grew rapidly into a widespread movement of groups of women working voluntarily to promote health and development in their own localities. Its most distinctive feature is the emphasis on group action rather than on individual community health workers.

When the project started, Selina Maphorogo was working as a nursing assistant in the hospital. She was asked to join the team as an interpreter, but she soon began to play a more and more important role in the project, eventually becoming its main leader. Her understanding of both the local culture and the need for changes which would lead to better health, and her special charisma in working with people, helped to shape the way in which the Care Groups developed, and contributed very largely to their success.” (The “Eye Doctor” Erika Sutter)

Learning on the job

“In the beginning I did not like to work with the Care Groups. When the Eye Doctor chose me to go out into the community, I did not understand why I should go. I found it was a big thing I could not manage. I even thought these people organising the project were not telling me the truth, they just wanted to get rid of me in the eye hospital.

When we visited the villages, it was my task to explain trachoma to the people and motivate them to act on its prevention. I started by teaching as I was used to doing in the hospital. Patients come to the hospital because they are sick. We give them health education because they happen to be there. We don’t ask them whether they like it or not, or what they want to hear. We tell them what we think they should know. This is the way it is done in the hospital. But in the community it was different. The people were not interested in my lessons, and I was frustrated. I just told them what to do. It was not very effective. When I asked them questions they used to answer ‘yes, yes’, or ‘no, no’. We were too much in a hurry and wanted to get things moving. And the Eye Doctor wanted to hear a report that things went all right.

The Eye Doctor gave me books to read, but they didn’t help me. I tried to read the books to the people and translate, which was not the correct thing. Then I asked some nurses to help me, and they said it would be easier if they would write something for me which I could read to the people. So I did this, and I was surprised to see that people still did not listen to me. I was always thinking, ‘Why are the women doing that? What must I do?’ I was so frustrated. I used to cry. It was too difficult for me to work in the community.

At last I decided to change my method of doing things. I started to visit homes, to sit down and relax and talk with the people, introducing myself in order to make friends with them until they were used to me. In this way I got the stories from the old ladies. I had already heard some stories from the old people when I worked in the eye department in the wards, and I got more stories out in the community.

As I was supposed to work with the groups I felt quite guilty when I went to talk to people at their homes instead of meeting with the group. Nobody told me to do that. It was my own secret, and I did not tell the nurses or the Eye Doctor.

I learned most from the grandmothers: the way to be respectful; the way to approach the elderly, and not to look down at their customs. Then I realised that it is important to sit down with the people and to discuss instead of giving lessons. I learned that just to give lots of advice and tell people what to do does not help people. Instead of encouraging them, it makes them feel ignorant.” (The Care Group Motivator Selina Maphorogo)

The early days: Trachoma control

“The Care Group movement grew from a project that was originally initiated with the limited objective of controlling the eye disease trachoma. Trachoma was one of the most common causes of blindness in the area around Elim Hospital in the 1970s, and our surveys showed that on average almost 50 percent of the children aged 2 to 4 years were severely affected by the disease in its most infective stage. Most of them lived in the most poverty stricken sections of the villages where personal and environmental hygiene was weak. In contrast, in the better off families, like those of teachers, shopkeepers or taxi owners, we found only a few mild cases of trachoma.
At that time only a fraction of small children were brought to child health clinics. So not only the improvement of hygiene, but also the treatment of the children, would have to be done by the mothers. We had to aim at active participation of the people in the affected communities, especially women.

A first trial of this concept was started in 1975 by staff members from Elim Hospital. An especially needy settlement was chosen, which was one of the worst places for trachoma. It was some 30 kilometres from the hospital, and could only be reached along poor roads. The key persons – chiefs and teachers – were approached for permission to work in their village, and the local women's club agreed to help. The members of the club were instructed about the nature of the disease, how it spread, and how it could be prevented. They were shown how to apply the ointment and were provided with a supply of it. They were to treat all the positive cases identified by the health workers and to reinforce the health education. The scheme appeared to be well accepted by the community.

However, soon after the initial phase the summer rains started, and the roads became impassable, preventing any monitoring of the programme. By the time we could visit the place again, the ointment had been used up – but the people in the poor section of the village, where trachoma was severe, had not received any treatment. The members of the women's club had refused to go to the ‘dirty’ people living there.

We had started with only very rudimentary knowledge about community involvement in health care, and we had to ask ourselves what had gone wrong. We realised that firstly, the project was imposed from outside. The team from the hospital had obtained permission from the village authorities, but the people concerned had no say. Secondly, we had not been aware of the social division in the community. The members of the women's club belonged to the higher social class in the community, where trachoma was not a problem, and therefore they had no vested interest in the project. Finally, we realised that in very poor communities, where most people have to struggle simply to make ends meet, there is not much time or energy to respond to a new venture.

In 1976, we made a new attempt, choosing settlements where people were already active in community development, with a team that included the ophthalmic nurses, and Selina Maphorogo as an interpreter. We started by asking the village authorities in each community to organise a mass meeting, where the problem of trachoma was discussed. In each settlement, volunteers came forward to help. In due course, they organised themselves into groups, electing their own leaders. A name had to be found for them, and ‘Care Groups’ was suggested – and has remained to this day.” (Erika Sutter)

The Community is my University

“People have very good ideas in many cases. From the elderly I learned about what they do in cases of measles, or when they are sick. For example, a child with measles is isolated and given milk to drink. They may put something in the eyes, which can be wrong, but this we can change. When I find out from people how they used to do things traditionally, I never blame them for doing something wrong. I always first praise them for the good things they do. This makes them happy and they see that we respect them, and it creates a calm atmosphere. After this I can carefully correct the dangerous things they may do by replacing them with something useful.

When the Eye Doctor left it was a challenge. We wanted to show that we could keep the Care Groups going alone. When I told the groups she was leaving, the members were very disturbed. They asked: ‘What will happen without her?’ I asked them: ‘How often have you seen her?’ They answered: ‘Oh, once or twice.’ I said: ‘You see. We pick all she has in her head and put it into our heads. And when she flies home to Switzerland, she will be quite light.’ So they were happy.

This is the most important thing for people; to trust. If they don’t trust somebody he or she can say things that are good and useful, but people will not accept them. But I realised that for things that have to do with culture I must be very careful and find the correct way to discourage something that is not good. All the time, I was learning more and more from the people, and I could compare what I knew from reading, or from the doctors, with what the community knew.

One does not need to be educated to improve the environment around oneself. I did have the opportunity to attend some training courses, but I still say that, ‘Care Groups are my University’, because I learned most from the people themselves.” (Selina Maphorogo)

The story is not over…

“Full participation of the community is important. People should not only be asked to contribute when their labour is needed, but be allowed to take part in all the steps of project management: thinking, decision-making, implementation and evaluation. When this happens, development projects strengthen the community. The people are able to organise themselves and their leadership will be strong. Once the community has learnt to solve a particular problem this leads to further development, as they will be keen to find ways to solve other problems, and it will be easier for them to do so.

We have two main donor organisation from Switzerland which have supported the Project since its early stages. Without them we could not have run the Project. They have a good way of dealing with us. Their field officers visit the Care Groups regularly. What I like about both these organisations is that they allow for sufficient time to organise step by step, discussing each step with all the people who are involved. In this way everyone is with us at each stage, and we have a better chance that the Care Groups will also continue in the future. Both these main supporters demand regular reports from us. This helps to educate the people in the Project to give feedback, and to use the funds properly.

In my heart I feel very happy. All the time during my work I used all my strength and knowledge so that what I intended to do should be successful. Now I am happy that the community can do it themselves, and that the Care Group Project is in good hands, and the good work will continue even after I have retired.” (Selina Maphorogo)

*Reading at the Symposium “Community Action for Health” illustrated with photographs by Erika Sutter. Source: Selina Maphorogo and Erika Sutter: The Community is my University. A voice from the grass roots on rural health and development. Amsterdam 2003 (KIT Publishers), ISBN 90 6832 722 4. The powerpoint slides of this presentation can be ordered at the MMS office: info@medicusmundi.ch