When I first heard that a group of Guatemalan clowns were staying with some of my relatives on the East Coast, my interest was piqued. A few Facebook messages later I learned that the clowns weren't the Ronald McDonald type but instead were professional health educators - part of a non-profit organization aiming to increase awareness of HIV and other sexual-health issues among vulnerable populations. Several members (i.e. clowns) of the Asociacion Payasos Atz'anem K'oj have come to Washington D.C. to present at the International AIDS Conference, and - still intrigued - I recently spoke with project coordinator Anthony Savdie about their work.
Who first identified a need to address sexual health and human rights in vulnerable communities? And what led to the establishment of Asociacion Payasos Atz'anem K'oj in 2001?
The need to shift the focus to the rural poor was first identified in a report from the Food and Agricultural Organization and UNAIDS, called Sustainable Agriculture: Rural Development and Vulnerability to the AIDS Epidemic, which was published very quietly in 1999. It outlined a series of vulnerability criteria for communities where statistics don't yet exist. Paul Farmer, MD, PhD, has also written about HIV, in Haiti and elsewhere, and he persuasively argues for a public-health effort that uses an analysis of poverty as the lens through which sexual health is examined. We in Guatemala - and by we, I mean the original team of Proyecto Payaso, a group that included an HIV educator, several performers and others interested in developing a project to address the issue - recognized a situation in the indigenous majority of the Western Highlands that clearly put large segments of the population at risk. Migration, poverty, and a lack of access to condoms, testing and basic information all seemed to point at the region as the next epidemiological time bomb.
The Atz'anem K'oj Collective formed in early 2001 to propose a communications project based on organic, face-to-face exposure to accurate, up-to-date and scientifically proven information formulated in a way as to be intelligible to people with little Spanish and little exposure to formal education.
What is the current state of sexual health and HIV awareness in the Guatemala? Who has the biggest need for accurate information?
The pandemic has exhibited worldwide tendencies over the last decade that have been very well documented: HIV is affecting, increasingly, women and the poor, and it is shifting disproportionately to rural areas. Indigenous women in Guatemala fall under all three categories; it is therefore logical that they should be the most vulnerable both to the spread and to the impact of HIV. Cultural mores that dictate women's subservience and ignorance of their bodies, health and rights have conspired with centuries of structural violence and historical neglect that have kept an estimated 85 percent of indigenous women in Guatemala from basic services such as education. We know, then - with or without hard epidemiological statistics - that women are under-resourced in terms of sexual health.
If we look at reproductive health statistics, which actually do exist, we have an indication of the general state of women's health in Guatemala. It is, as you may guess, not very good. Maternal mortality is almost the highest in the hemisphere, second only to Haiti, and the only reason, in our view, that HIV statistics among indigenous women are not through the roof is that testing and counseling services are nonexistent in areas of indigenous majority.
Your clown-educators - who, I understand, perform in big shoes and red noses - use games, workshops and theater to increase access to information and resources on HIV. Can you provide a few examples of how this is done?
A board game gathers twelve people around a 50-square circuit, and it's a race to the end with the roll of one or two dice. If you roll a six, for instance, you land on a square where you are asked to put a condom on [an object] following the correct steps. If you roll a five you are instructed to pick from a stack of hypothetical situations and asked to determine whether you are in fact in a risky situation - whether the described behavior could end up causing a new infection, either HIV or some other STD. Another square announces that your HIV test has come back positive and asks you to discuss whom you might tell first and why, another square asks you to name three bodily fluids capable of transmitting HIV from one person to another, another tells you to roll again because you went to the health post and asked for condoms and they gave them to you. You get the drift.
Another game draws on the other side of the brain and asks you to put together a 50-piece jigsaw puzzle where the specifics of six STDs are listed - whether they are treatable, what the symptoms are, how they are detected. Another uses the concept of Wheel of Fortune to spin a wooden top that points at one of four categories of questions: prevention, human rights, sexually transmitted diseases, and behaviors and attitudes. Small traps are laid in case participants get too confident about their knowledge or their skills or their understanding of issues related to sexuality and sexual health: You might be told to skip a turn because you think you're too much of a macho man to put on a condom. Answers are judged by the group and rewarded, as the case may be, with a grain of corn or a bean or a button (we are a low-budget operation).
The workshops are standardized 90-minute affairs facilitated by peer educators during which single-sex groups get to participate in activities that leave them with a better understanding of HIV and its general behavior, including biological, social and ethical considerations. There is also opportunity to air questions and opinions and to discuss appropriate community responses. The tone varies slightly according to whether the group is composed of midwives, evangelical pastors, sex workers or 16-year-olds in custody, but the content stays roughly the same.
Where else has clowning been used publicly to educate about HIV and sexual health?
Apparently a month before we launched officially in 2001 a group was using clowning for HIV and human rights communication in Ethiopia, a happy coincidence. Since we have been active, we've run an exchange program that has enabled young professionals from Peru, Venezuela, Honduras, Nicaragua and Jamaica to come to Guatemala to work with us for several months and put together projects in their home countries that associate the arts, particularly clowning, with sexual health and human rights.
You're about to launch a pilot project to offer free HIV testing and counseling in areas with the greatest need. Whom will you be targeting, and what is your ultimate goal with this work?
With the assistance of Health for Humanity, an NGO based in Vancouver (with which we have been developing a certification course over the past few years in sexual health and human rights for HIV activists), we'll be focusing a pilot testing service on indigenous people who don't normally access what few services do exist - because they're not pregnant women or sex workers, because they're prison inmates without access to sexual health services, or because they don't have a realistic perception of the risks that they're taking and don't see the need to test. We want to make testing and culturally appropriate counseling available to the families of HIV-positive people and to young men and women in socially vulnerable situations in the areas of indigenous majority in Guatemala's Western Highlands, since these areas are the ones with the lowest service provision and the greatest uncertainty regarding rates of prevalence.
The lack of hard statistics has for years justified gross neglect on the part of health authorities towards indigenous majorities, and generating more realistic figures is an essential part of attracting appropriate and equitable levels of resources, services and expertise to historically marginalized areas of the country.
What do you consider your organization's greatest accomplishments thus far? What evidence is there that your work is increasing HIV awareness and enacting change?
Merely to have stayed afloat is a bit of an achievement, in my humble opinion. But seriously, it's hard to look at any one advance in the community response to HIV in Guatemala and take credit for it. We are an active part of civil society, and this is, I think, where community-based organizations can contribute the most: We can go where governments can't or won't go and where large private voluntary organizations are not able to reach. We've formed human resources in sexual health communication in an area where there previously weren't any, and we have done it in a playful and lively and effective way.
Among other accomplishments: We've pioneered printed HIV information for low-literacy environments in indigenous languages. We've developed a methodology in communications in sexual health and human rights with social transformation as an end goal. We've helped create an environment that enables women, indigenous people, sex workers, people with HIV, prison inmates and other marginalized communities to develop the tools they need to increase their well-being and their quality of life. We've participated actively in a dozen conferences and shared the lessons we have learned with our peers and with sister organizations across the board. And we've maintained a sense of humor in the face of extraordinary violence, natural disasters and political turmoil. None of these are big wows by themselves, but taken together we can look in the mirror and like what's there. We are aware of being an infinitesimal part of a wider movement.
In terms of enacting change, we've run formal evaluations measuring both the impact and process of our programs and acted on their recommendations, and the evaluations consistently report that art and peer education have measurable impact in terms of the retention by vulnerable individuals of essential information. We've presented the terms of the debates on sexual diversity and sexuality to people who come from conservative rural cultures and stimulated ongoing discussion and interest at the grassroots level. And we've distributed about a zillion condoms.
We hopingly, cheerfully look forward to the future as we launch into our second decade, with an ambitious strategic plan under our arm with the ink still wet and with a team of clowns that can't be beat.
Photo by Jessica Eve Rattner