One Health. Группа авторов
TD workshops, held in May 2018, community leaders accounted for 31% of participants, with more women participating.
In summary, offering a platform for balanced participation required modulating power differentials through three mechanisms: (i) inducing self-reflexivity of participants to acknowledge diversity of experiences (the exercise with animals); (ii) participants’ understanding of the difference between emic and etic constructs leading to bias or mutual understanding (the culturally significant picture exercise); and (iii) acknowledging the value of diverse views to address zoonosis as a health topic (through translation and use of flashcards for equal representation of views). Once these three preconditions were met, a successful negotiation of interests (avoiding power overrides) was possible. Figure 6.3 shows the adapted reflexive approach derived from backward planning used to develop specific tools as modulators of change, in order to achieve the desired goal.
Fig. 6.3. Adapted reflexive approach derived from backward planning used to develop specific tools as modulators of change, in order to achieve the desired goal (overlaid with Fig. 6.2). For each condition, workshop participants were asked to define the needed modulator of change.
This reflexive process was used throughout the project life to make sure that the team went from a multicultural approach where many ‘cultures’ or knowledge systems coexisted without cross-over understandings, towards an intercultural approach where mutual learning and knowledge co-production was promoted. The pragmatic value of this approach is seen in the following outcome.
A surveillance system for detecting signs of two targeted zoonoses was implemented. In order to increase sensitivity, case definitions for respiratory, febrile and diarrhoeic syndromes were initially developed by epidemiologists and presented to the multicultural academic team. Maya health personnel discussed among themselves how erroneous the biomedical terms were according to local understandings. Noticing a reluctance to publicly contradict a senior epidemiologist, social scientists developed an exercise inviting each team member to propose new categories for surveillance from their own emic perspectives. What followed was a discussion on 23 different Maya Q’eqchi’ terms that local indigenous people could use to define different types of fever, diarrhoea or respiratory illness. This elaborated range of local terms was used to prepare research instruments to test how local people perceived each syndrome. Results of these analyses were later used to develop materials for communication campaigns for explaining at household level how surveillance would operate. Most importantly, it helped Maya health staff unify recruitment criteria for Maya patients for whom case definitions of the protocol had to be completed. Throughout the project the field team met on a regular basis to discuss new emic categories that emerged during interactions with patients. This increased the cultural pertinence in medical response and provided culturally relevant ‘danger signs’. For example, whenever a patient indicated they had ‘susto’ or ‘itzel yax’, the health team knew it to be an illness in dire need of attention. We could show that awareness of emic categories of disease reduced misconceptions leading to erroneous interpretations of medical data, while it increased mutual understanding between representatives of different epistemic systems (Berger-González et al., 2016; Hitziger et al., 2017). However, this awareness did not occur without facilitation, as depicted in Fig. 6.4. Communications that nullified the experiential reality or identity of indigenous persons, called microinvalidations (Christopher et al., 2008), and attitudes of ‘cultural discounting’ were observed. The latter were based on the assumption that indigenous partners were passive recipients of knowledge to ‘improve’ their livelihoods and could not contribute usefully to the research. The critical analysis of inter-ethnic relations served as a base to modulate spaces for equal participation, which included constant reminders to use all languages, to address all relevant emic categories, and to promote respectful listening skills. This facilitated multidirectional conversations rather than unilateral information transfer. Health teams learned to replicate this process with patients and were rewarded with rich insights into Maya healing systems and a better understanding of perceived desirable outputs in collaborating with the public health system.
Fig. 6.4. Backward planning tool employed to increase sensitivity of the surveillance system implemented for detecting two targeted zoonotic diseases in Maya communities of Guatemala.
Transdisciplinary process in the Jigjiga University One Health Initiative (JOHI)
JOHI is a research-development project currently implemented in the Somali Regional State of Ethiopia to create innovative integrated health systems for improvement of health and well-being of pastoral communities. It is a 10 year (2015–2025) project co-funded by the Swiss Agency for Development and Cooperation (SDC), the Swiss Tropical and Public Health Institute (Swiss TPH) and the Jigjiga University (JJU). The project includes three main actors: (i) JJU for legal status and curricula; (ii) Armauer Hansen Research Institute (AHRI) for policy and research support and technical collaboration; and (iii) Swiss TPH providing technical expertise.
Setting up the project followed a process of extensive consultations with communities, authorities and technical experts within participatory processes in Jigjiga city and Gode, the main city of the study area in Adadle district (woreda). A preparatory workshop took place between representatives of the JJU, AHRI and Swiss TPH together with SDC staff in September 2014. The inception phase aimed to prepare the full project document. A stakeholder workshop in March 2015 in Jigjiga identified the main priorities of communities and representatives of the regional government bureaus. A first batch of PhD and MSc students went to be trained at Swiss TPH in the fields of human nutrition, midwifery, tuberculosis, animal health and rangeland management. Upon their return, the students prepared their field work. In June 2016, the supervisors together with the project accountant visited JJU and the field site in Adadle woreda and met the local authorities and communities.
The field studies and data collection were done as one interdisciplinary team in the Adadle woreda from July to August 2016. The second batch of students was similarly elected, by interviewing candidates. A stakeholder meeting was held in Gode at the end of February 2018, and first decisions were made on proposed interventions based on the research in tuberculosis control, integrated surveillance and response adapted to pastoralists and water and sanitation. Unexpectedly, the mayor of Gode requested support for an abattoir and better meat markets. A steering committee and a further stakeholder workshop were held in Jigjiga in May 2018, and the proposed interventions were further discussed and approved. Interventions were subsequently implemented, and upon the first results, communities and authorities met again with the interdisciplinary research team to discuss next steps together. Communities were faced with the challenge of financing fuel for emergency ambulance services, so JOHI assisted communities in organizing to raise emergency funds. Additionally, the project team engaged in developing an abattoir and a safe meat marketing system, taking up local priorities that were not in the initial plans of the project. All actor groups remain involved in the sharing of knowledge and expressing priorities for further health development actions.
National and regional priority setting in health and food safety
Regarding societal questions about health, priority setting is not only needed in research and action in specific contexts but also on national and regional levels. As such, new public engagement processes can be initiated. For example, the European Food Safety Agency (EFSA) initiated an integrated approach towards risk assessment with a special focus on human health and the whole food chain, as well as on science-based interventions to lower consumer risks. They regularly consult with scientific panels to address complex, multifaceted questions of risk and experiment with how to engage the broader public. This consultation process revealed, among other things, increasing public concerns about the sustainability of livestock production systems, acceptability of food quality and animal welfare issues (Berthe et al., 2013).