In 2004 the Infectious Diseases Institute (IDI) at Makerere University, opened as a new HIV treatment centre in Kampala, Uganda, with Keith McAdam, a physician and professor of tropical medicine, as its first executive director. At that time, many people living with HIV there were dying in large numbers; coffin makers were flourishing. AIDS was a devastating fatal disease in the days before anti-retroviral medicines (ARVs) were available.
However, as soon as highly effective ARV combinations were available in Africa, there was a tsunami of demand for treatment. IDI was providing life saving treatment and the numbers who came to the IDI for care was overwhelming the facilities of the institute. We could not cope with the numbers of people who were waiting in the clinic for hours, moving up one space at a time, quietly and self-consciously, because of the fear and stigma of being recognized by someone while they waited to see a care provider.
We had to consider how to change the paradigm for care. Instead of attempting to provide a model of care that was appropriate in North America or Europe, we wanted to change the system of care to a more relevant African model. This started with a re-examination of the name we used for those we served, our patients. We tried ‘clients’ for a few days but no one liked that, so in consultation with the patients and staff, we changed to ‘mikwano gjaffe’, which means ‘our friends’ in the local language, Luganda.
A ‘creativity initiative’ was started in the clinic, led by the Friends, whereby they could participate in creative activities while they waited, including music and dance, art and crafts, board games, entrepreneurial skills training and social and spiritual support. The clinic was transformed from a silent ‘morgue’ to a vibrant ‘market place’. Within a few weeks the ambience of the clinic changed dramatically.
From being stigmatized and embarrassed, many Friends became self-assured and confident of their ability to help others living with HIV. However, they needed training to become change agents for their communities. Elspeth McAdam brought a whole new dimension to the situation; as a child psychiatrist employing appreciative inquiry very effectively in her clinical practice in UK, she helped create a training programme that could be used in a public health setting to transform Friends into Change Agents.
In teaming up with Alice Welbourn, the creator of Stepping Stones, we were able to examine how we might best approach the creation of a short public health intervention, utilizing appreciative techniques. She had already developed the most internationally successful ‘training package on gender, HIV, communication and relationship skills’. Charles Steinberg was the next person to bring his skills to bear on the challenge, as an experienced HIV physician from the USA, who was at that time head of training at IDI. Kicki Oljemark brought to the group an inspiring energy and interest in appreciative inquiry and strength based training in the health care sector and in leadership development.
This team of five worked in relays over the next four years to develop the training package initially in Uganda. Their intention from the beginning was to develop a different and much shorter package that could be used as a public health intervention to help prevent the spread of HIV. They sought ways to support people living with HIV to feel empowered to be part of the ‘solution’ rather than being considered as the major public health ‘problem’. The creators of NAMWEZA avoided all use of negative messages and instead employed the affirming techniques of Appreciative Inquiry to help build self-esteem and self-awareness.
The name NAMWEZA is a catchy appreciative title for this life-skills training programme. It derives from two Kiswahili terms. NAM is a colloquial term for ‘Yes’. WEZA derives from ‘pamoja tunaweza’ (together we can). The NAMWEZA package has been copyrighted.
Colleagues at the Centers for Disease Control (CDC) in the US enthusiastically approved the concept of this public health behavioural intervention, as one of the facets of a strategy for addressing HIV. A multi-country public health evaluation of this intervention was planned for Uganda and Tanzania. After a long incubation period, a research proposal was funded through CDC in Tanzania, in a collaboration between principal investigator colleagues at Muhumbili University Medical School (Professor of Psychiatry, Sylvia Kaaya), Harvard University School of Public Health (epidemiologist, Dr Mary Kay Fawzi) and CDC Tanzania (genito-urinary consultant physician, Dr Gilly Arthur).
The appreciative exercises contained within NAMWEZA are being used in different settings already, in addition to their research evaluation in HIV prevention in Tanzania. This includes a programme in schools and a project with delinquent children in India, work in prisons in the UK and with street children and community development in several countries. Others are interested in the application of NAMWEZA as a public health intervention in different settings.