 think we'll go to the next paper. So we have Juliet Waterkin from Africa, a very interesting organization that I think has its roots in Zimbabwe and I think some of the the Community Health Club, if you like, the inventive and innovative spirit has come from this organization and they've with very little support compared to some of the other sort of bigger organizations they've managed to actually put together some really interesting results. So this is the reason why we're here today. I think you're very much encouraged to collaborate with Africa ahead after this meeting. If you don't already have that linkage, you're very welcome to make that. Good morning everybody. I thought I'd just bring us down to basics. We're all people, we all have our families and we're here today to talk about family survival and this is a picture of my grandson. I thought it would be very appropriate because here's a little boy who's only about six months an arm. He's an absolutely delightful little boy, healthy, well looked after in a clean environment, but just to focus our minds on child survival. For every child like this, there are 16 in Africa that don't make it and I think that's a very, very, if we remember one fact we should remember that we're here today, not really just to sort of punt our particular methodology or to try and sell our wares. We're actually here to try and save lives and we are mainly concerned with lives in Africa. We're trying to get the maximum we can out of a project and address as much as we can so that you get as much bang for your buck. So when you look at this, our idea is to look at three themes. I know that we're all professionals here and you've given the whole, you know, a lot of thought to how to make things work, but I'd like to concentrate on three main themes which sort of really resonate with the Community Health Lab model of development. The first one is the holistic approach to disease prevention, i.e. not just looking at diarrhea. There is more to life than diarrhea. I think that our sector, the wash sector, tends to get focused incredibly much on diarrhea so I'm going to take you through a few reasons why we should look at other things. Secondly, I want to revisit empowerment of women. It's an idea which has almost deadened us. We've heard it so much, but really it is the basis of good development. And thirdly, positive peer support. We're talking about support. We're not talking about pressure. We're trying to look at behavior change as a form of behavior which comes when the majority want to do something. So these are all sort of social psychology behind the Community Health Club which is what I was built to talk about. But in fact what we're talking about here is the mechanism for change. Why it works. You'll have to believe us it works. If you don't believe us, you'll have to come and see it and Anthony is going to talk to you about that. But I'm going to try and explain why I think it's working just from my own personal perspective. I'll go back to a story. I went to Guinea-Bissau seven years ago. It's one of the poorest countries in Africa. I was on a trip to take photographs of these beautiful children and then I came across Sene. Sene is a one month old baby. I want to focus on Sene because when we look at statistics, we should remember that. This is going very fast. The mortality of under fives, if you look at one child like Sene who died and you're looking at six million that died or six millions that we could have prevented in the last year, there were deaths that were unnecessary and they were due to a number of causes. Again, this is a UNICEF well-known UNICEF table a lot of people use. And if you look at diarrhea, it's only 17% of the cause. There are other causes here which we tend to ignore. Pneumonia, ARIs is a major cause of death amongst small children. We're looking at Neonatal, little Sene who died of Neonatal tetanus because she was actually delivered with a rusty blade and never ever recovered. This is the reality. We're looking at the statistic here, but just that quick glimpse of Sene will remind you that how many children lost their lives through poor delivery methods or not getting to the delivery place and time. The injuries, the pneumonia, the malaria, measles can be prevented and HIV can be prevented from mother to child transmission being controlled. In our work, we can actually reduce so much through good hygiene and sanitation. Neonatal can be reduced by 44% by good birthing practices. Diarrhea can be reduced by 88% and ARI, Pneumonia, over 30%. So if we can do this sort of reduction, we should have interventions which allow this maximum, the spread over all the diseases and not just focus on a few simple diseases that we can tackle. Again, we know that malaria can be reduced by, they say 50%, I'd say more by ITNs. Immunization can practically wipe out, eradicate malaria measles. These differences, if you look at this, this is a slightly rule of thumb kind of difference, but I calculated, for example here, this is the number of cases that were, if you had a community health club, which is this yellow, the first year of training in a community health club, if you go by those previous reductions that I told you, like 88% diarrhea, 40% reduction of other neonatal, if you calculate those, you can actually reduce the number of cases. So here I've taken 100, say this was 100 cases, you could reduce it from 37 to 21. If you went to the next year, which is what the next year in our health clubs become more interested in nutrition and they become called fan clubs, food, agriculture, nutrition clubs. If you go to the second year, you start focusing on nutrition, you can see that most of the diseases can come from the first year, but it can be halved if you've got good nutrition, i.e. if a child has malaria, it can survive, it has 50% more chance of survival if it's well nourished. So if nourishment, good nourishment is one of the key things. So we don't just leave it at, you know, washed diseases, we go into nutrition in the next phase. So if you get down to here, the green side, this is 14 cases as opposed to 37, you go from pneumonia, it could be reduced from 19 to 8, all the way down. This sort of, I mean, it's very, very rough and I wouldn't say it's scientific at all, but this is our inspiration, this is what we're trying to achieve, reduce as much disease as we can. So we would be able to reduce the total amount of deaths we would be able to reduce or save, total saved 62 out of 88. You know, if you actually look at that, we're really addressing the problem of development. And just to encourage you, I mean, you may say that this has been hypothetical, it has, it is in some sense. But we had a program in Zimbabwe, one of the first programs, and this is why the data is, it goes right back to 97, actually up to 2001. This was the duration of the program. And this was the coverage of health clubs here. So you've got 80% coverage of health clubs within a catchment of a clinic. Now, when you've got, our argument is that you've got to have density of coverage, not just one here, one here, one here. You don't see the impact there because public health is something which has to be blanket for it to succeed. And that's why you need a very thorough intervention. Here, we could see that after, when we started, right, these diseases here, this is ARI, pneumonia, et cetera, skin diseases, bilhazia, and I think this is diarrhea, all these are going down, down, down, down. Now, this is an important thing. 2001 is where in other parts of this district, we actually, we stopped in 2001. And in other parts, not this ward, but in other areas, in 2001 where we stopped, it began very slowly to rise again. The pattern changed and went up. Now, in this area where we had been going for one, two, three, four, nearly five years, when we left, and this is the cutoff place in Zimbabwe, as you all know, Zimbabwe went down the tube in 2001 and the funding stopped. So, here was the cutoff point. Now, it didn't sort of start climbing again, it continued straight. More research needs to be done on this, but these are reported cases. A lot of people are skeptical about that, but it does show a pattern, and we could see the pattern comparative to the other control groups. In, in 2008, in Zimbabwe, everything seems to happen in a big sort of, it's always very dramatic in Zimbabwe. We, we had an incredible cholera outbreak, as some of you may remember, there were 10,000 cases of which four and a half thousand died. And we were asked to work in Mutari City, in one of the most high-density areas, Sukubva, where there was a market of people coming across from Mozambique, and the cholera was coming through that border to this big market, and they expected it to be one of the hotspots there. As an emergency program tying up with Oxfam, we started community health clubs here in huge numbers, oh dear, and let me go back. And so this, there were about 50 community health clubs here, and the numbers, about five and a half thousand members, they all, as you say, the green card, this is what they're learning. They're incredibly focused on, on cleaning up the environment, there were huge cleanup campaigns, the marketplace was cleaned up. I went, I had an extraordinary time going with the Environmental Health Department who couldn't believe their eyes, because the, all the solid waste had built up in huge mounds, because the local council was not able to cope with the, with disposing the solid waste. And the community health clubs cleaned it up, burned it, separated it out, non-organic, organic, and it was an amazing process. And you know, what we learned from this was that the council took hard and they said, okay, well, we, we can deal with the rest. And there was some open storage near where the first cases were, they got that cleaned up. So it's really sort of putting government into a position where the people have rarely shown them up for what needs to be done. And it, working together with, with government is, is what we do. We work through the Ministry of Health, which has to be emphasized, we, we're not just a little NGO on our own, all we're doing is really trying to work with government, making government more effective. So, when we, we've, you saw the membership card, I think it's quite amusing here, they actually sort of written it out on their tree, this is their meeting place where they meet, and this is in Shawna, and actually you've seen this, but these are the typically the sort of subjects which we would address. And here you can see the holistic nature, we look at Bilhazia, malaria, worms, skin diseases, HIV, nutrition, sanitation, etc. Sanitation is right down at the end here, because actually by the time we've been through all these sessions, we've stressed sanitation so much that we, we don't have a difficulty getting people to build their latrines. They've heard it from every single source, there's not a big sort of coercive effect, it's just, yeah it's obvious, we need a latrine. And you'll see in, in some of our statistics, as you're welcome to have a look at some of the information there, you'll see the enormous response, it not only creates a demand for sanitation, but people are building their own latrines, if that's your interest. I know that the interest has been on sanitation in the past, but my particular sort of point I want to make is it's not just sanitation. And again, a slide very much like the one that was shown from Miranda. This is our basic, we always produce a bar chart like this, the, the, the baseline is taken through community monitoring. They have a, which is actually the community that health clubs themselves go through and they take records, it's called an inventory of all the facilities in each household, because the households themselves know what they've got and the, the health club, the chairperson of the health club has been given that responsibility to monitor the health club. So they go around to each and every household and they do an inventory of what they've got. At the end they go back and do the inventory again and this is what you see the difference between the before and after. And you know, I won't dwell on that, but the, the details are very, very interesting. There are five and a half thousand members, um, 121 health clubs. So you can see that what we try and do is not approach individually, but move the whole lot up together. So they started, um, you know, most of it was around 40% coverage. By the end of it, most of it was up to 80% coverage. So, you know, there's some way to go in some of these different places, but basically, um, you can see there's a general uplift of the group and the average of 16 indicators is 23% in six months. Um, oh sorry, the average was, uh, the average of all 16 indicators was 79%. So if you took them all, they were almost 80%. So how do community health clubs work? Um, now just looking a little bit at the social psychology, we want to, we want to understand why, as Arne says, why do we get this buy-in? Why do people come in such numbers and, you know, look at the empowerment of women through group support, because basically we are very sociable people. Um, I'm sure we've all, development practitioners, you have, you refer to community the whole time. Now what do we mean, mean by community? When we actually say we're going to the community, we sort of just take it for granted in a strange sort of way that the community is a formatted group. They're out there, the community. And I really beg to differ. I really think that we should look at it. Is the, what we would say, common unity? That was the word, common unity. Is the common unity in a community? Very, very seldom, very seldom. I hate to be cynical, but really, you know, you've got, this is the village head here, an old, uninspired, pretty dirty old guy who's really not into, you know, what we're talking about and he kind of is there for the long run. Um, you know, women, men, yep, do they have a common vision? We found that really what we need to develop is that common vision, that common unity. Not take it for granted, and this is the trick, is don't take it for granted that they're functional, build that functionality. If they are functional, you'll build it even higher. So the difference is here with women, um, the incredible inspiration, you know, they're so lively, they're so, so excited about what they're doing, they're learning. Um, here they're looking at different food groups. Here they're doing peanut butter making for, for weaning. Um, a simple little, uh, appropriate technology here, what we did with the health clubs, each health club at the end of their, uh, six months training they went on to the next phase. We had a tiny, tiny startup for each club to identify a project that they wanted to do. They grew peanuts, we gave them that little peanut, um, um, masher thing, and you know, this was something which radically transformed the, the intake of, of, um, weaning food for a lot of children. I've got wonderful quotations from many, many women that I've interviewed, and we asked them what's the difference between a non-member and a member? And they said, well, non-members have quite a lot of misunderstanding amongst them. They spend quite a lot of time quarreling, but for us club members we're always doing something constructive. And this is really what we like to do. I mean, everyone likes to be constructive. The ideas, if they're pushed out there, they are taken. It's like they've got a hunger, a hunger for knowledge. And this is why they come in such, uh, quantities. Here you'll see the IDP camps in northern Uganda. This is three clubs met together here. Um, the sense of identity that you get by, um, having a club, it's probably something we've forgotten. You know, we've forgotten how amazing it is to say, I'm a health club member, and the inspiration for this really came from the scout, the Boy Scout movement, where, um, you know, little boys there squeaky clean, getting dressed up in their little suits and everything. And, you know, they go off with their card and they're really keen to get their task completed. And it was the same sort of ideas to try and get people enthused about completing a whole, um, list of tasks. And, you know, the only thing we give, the only thing we give in the whole program, the whole one year program, is this funny little certificate here. And I can tell you, this is really something which turns people on. It's unbelievable how much pleasure a certificate will give to people. Um, we had one little old lady saying, you know, when I was, um, when I was born, I got a certificate, and actually I didn't think I was going to get another certificate till I got my death certificate. Now I've got this, I've got this, and my husband's so proud of me. They frame it, they put it on the wall. These are simple things which motivate, motivate people and, and really gives them the sense of being acknowledged by the community. But when people know that you're a community health club member, they'll come and visit you because they know that your latrine is clean, that your house, you won't get diarrhea from eating your food. These are, these are things that they tell us and it's really, really encouraging. This is inside of a community health club, um, members' kitchen. Beautifully polished. These are made out of, out of clay, polished. Everything's beautifully displayed and she actually won, you know, she was one of the model homes that won one of the, the prizes. So, um, yeah, we're a little bit inspired by, uh, something I once heard, um, some government official said to Mother Teresa, you know, there's such millions there, so many millions, like we're talking about trying to save six million lives in Africa. Where do you start? And, and the government official said to her, you know, how can you be bothered? I mean, what impact can you make? And she said, well, actually, how do you count a million? You know, and they said, well, one, two, three, four, that's what we do. And that's what we do. We're counting. And we're counting and we're trying to get there. It's a, it's a, it's a big task and we need a lot of help from bigger organizations and through government. But you can actually make enormous, um, inroads into people. You just start. Um, a little bit of explanation for those who like this kind of thing. Even those who don't. It's just how I see it, how I see what, what, how our thing works is everybody says, you know, oh, well, you know, you know it, but you don't do it, right? That, that was a big argument for, for, for social marketing. Yeah. Everyone knows the things. Everyone knows they shouldn't smoke, but they don't do it, right? And we say, yeah, that's true. You don't, you don't only have to know it. You've got to know also the experience of what happens. For example, you know, if I, um, had a child like Senyi that died, right? I might have had the experience of actually knowing what it was like when a child had diarrhea, got dehydration and died. You know, if I had the experience of seeing my next door neighbors being rehydrated, I would then believe in ORS. So you need that personal experience plus the knowledge. You need the understanding. So the interpretation of facts is very, very often missing. And I think because we're such quick sort of, you know, well educated people, we forget that getting things through takes a lot of time. It needs a lot of reinforcement. It needs coming again and again saying the same very simple things, but always reinforced with good examples. So you've got to understand as well as know. But then you get to the point of can I do it? Actually, can I really build a latrine? It means digging a big hole in the ground. It means lining it. It means, you know, will my husband come back and make me break it down because I haven't got his permission. Can I really do it? My husband's not here. All that sort of stuff. So it's the self efficacy, the doubt. You know, rural women, especially those who've been left behind. You've not been educated very much. They haven't the confidence that we have to make individual decisions. So what I think we've been doing for a lot of time in development is we've been targeting individuals who haven't really got that confidence to make the individual decision. So our theory is, yeah, do the individual thing which they do need to learn. Everyone needs to learn, but then reinforce it by group. So you get the common knowledge. You get the common understanding in these health clubs because they're all looking at things together. And then they have a group consensus. They understand together and they understand as a group what should be done. This group consensus, of course, it's a very sociological sort of aspect. Underneath everything are values. What we value here is, you know, we value good development in this room. This is one of our values. Now, you know, the group, as a health club, will say, okay, what we value is clean living. These are our new values. So you get group values and it's the values which actually dictate behavior. What we've been doing is we've been going to the behavior without addressing the values. And that's why things don't stick. Change the values, change the core values, the group values, and then you actually change, you won't even have to change the norms. They just are dictated by the values. This comes from the group, this pressure, this support that comes from a peer group, then goes across to the individual and all of us here are sitting here going, yep, okay, this seems to be the thing to do. Okay, let's do it. The more people that decide to do it, the more the individuals who are either too lazy or too uninvolved, whatever their reasons are, don't do it. Those people will do it for different reasons. So everybody changes. Some people change fast when they have the knowledge. Other people change just because everyone else is doing it. So you're kind of catching the whole bunch. And just to focus on one woman, Mrs. Terira is amazing. One of many women who rose up through the health clubs, she was just a woman sitting at the back of the health club when I was visiting once and said, you know, what skills do you have here? And they said, well, not much. And I said, well, can any of you make pots? And she said, yeah, I can make pots. So right at the back said, okay, so why don't you teach you other people to make pots and we'll make beehives out of pots? And she went, okay, maybe I can do that. Well, honestly, two years later, she was the trainer for the entire, not only her health club, but the next door health club. She went to become the trainer for the, for the district. She, here she is, here still got the same shirt on you might notice. She now got a wig. She's smart. She's with our other two trainers. This lady was in a similar position at a graduation ceremony. And, you know, one of the nicest things that I, I heard from her is she said, you know, I'm not nobody now. And that was, this is, this is, this is what I used this for my, to summarize what I think about the health clubs is I'm not nobody now. You know, if you're out in the rural areas, you are nobody. Nobody's interested in you. But if every little person goes, I'm not nobody now. You know, that's changed. That's how you can empower women. So I'm just going to leave you with this nice little song, which goes, I hope, no sound, no sound. Okay. It goes, women are coming around the corner. Women are coming around the corner. Tell your friends that women are coming. Tell your government that women are coming. Women are coming around the corner. And this is where I think the power lies. Thank you very much. Okay. Thank you, Juliet. That was a great inspiration. We're running a bit late. But I, if there's a burning question, I will never stop on. So I guess we have one from Elizabeth Tilley from Avag. And you'll have to come up to the top here. So I did. My question was just, maybe you can just speak to the timeline. I got a little bit confused in terms of the one year and then the fan and then you said you were in the one district for seven years. Like, how does it continue and is there still intervention or does it run on its own? Just how that kind of works. Yeah. I think it, you know, it's so difficult in a presentation to say everything at the same time. Sorry about that. Probably was a bit confusing. If you look at the membership card, there's 20 to 24 topics. All right. And that card dictates the length of time of the training. And we meet once a week for two hours. So if you've got 20 sessions, it would work for five months or if you've got 24, it would be six months. So basically the actual intervention, the main intervention takes six months. You could say, you know, five to six months, but it's fluid, you know. Then this is, then that's the end of the first phase. It's a graduation. And if you're, if you're only in a wash project and there's absolutely no interest in anything else, very often it ends there. And basically the community on their own. But, you know, what we're looking for is more integrated kind of funding, really. And it's quite hard to come by this that, you know, there's more than, more than just the wash interest. In that case, we can go on to the second, third, fourth year. In the example I showed you with the peanut butter making in that district, we had a three-year program and the first year was health promotion, just the health clubs with the membership card. The second year was water and sanitation. There were a lot of latrines that were built. I think 2000 latrines were built during that year. And there was some water in another district. And then the third year went on to what we call FAN. It was sort of like income-generating projects. So, you know, it's a movable feast and it really is dictated by the funding. Okay, one more question. So there will be a discussion at the end. So I'm sorry. What again? My name is Daniel Diva. I'm a student at KTH. I understand that in many societies in Africa, we have this kind of setup where males dominate the households. So I would like to find out how have you handled that issue within the community health clubs because I say it's mostly women and there could be issues, you know, if I'm going to build a latrine that I don't have the permission of my husband, how do you deal with that issue to have the success that you've demonstrated to us today? Thank you. I think that's an incredibly important question. Thank you for asking that. We, you know, they're called community health clubs, not women's groups. And they're not mothers clubs. We're trying very, very hard to involve men in hygiene. It's a really uphill battle. It isn't something that comes naturally. Women naturally gravitate towards this kind of training. They love it. It's to do with their children. We spend a lot of time trying to encourage couples to come together. And, you know, if they do come as a couple and they get a certificate, we make a huge fuss of them at graduation as a sort of modern, progressive couple working together, etc. But the truth is that 80% or even 90% or even 98% are women in the health clubs. But it doesn't mean to say that the men are not involved. We do entry into the community through the village leader and we very much encourage that if he doesn't want to come along himself, that his wife should come along. And, you know, like all of us, the wives do a lot of talking to their husbands and the husbands actually monitor it through their wives. We found, we usually have a couple of symbolic men, even if the rest don't come, just, you know, keeping tabs on the fact we're not doing anything too subversive, like, you know, if they're against condoms or something, you know, the information comes back very quickly. It's amazing how the, because they're to do with hygiene, it tends to draw women in, but not exclusively. But I totally agree we are working on trying to get more men involved. But I think that comes with, you know, if there's a good example from the chief that the chief comes along and he tells all his mates to come, then the men come. But it is a bit of a battle.