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It began as a rumor early in 2005. A report here, a quiet word there. Enough to suggest that in the aftermath of the 2004 tsunami, the coastal villages of southern India might be in harm's way once more—this time from the deadly HIV virus.
Many experts thought these tight-knit communities were relatively safe from the AIDS epidemic, but with the death and displacement of hundreds of thousands, the social landscape—like the coastline itself—was recreated in a moment.
The rumors reached Jose Michael, director of Oxfam's HIV program in India—that people living in crowded temporary houses and communities were experiencing new pressures that could increase their risk of HIV infection.
"There were many possible triggers, but we had no evidence," says Michael, so while he continued the Oxfam HIV/AIDS awareness program, he and Hari Krishna, an Oxfam disaster response specialist, engaged a well-known Indian health research organization to determine whether and how the tsunami disaster and its aftermath was increasing the vulnerability of the coastal communities to HIV infection.
"We did not set out to determine actual rates of HIV infection in the villages," says Hari Krishna. "That would have revealed very little about the changes precipitated by the disaster and even less about how and why they took place." Instead, the research focused on how people felt their own HIV-related behavior had changed since the tsunami, and what brought about those changes.
The central difficulty in carrying out the research is obvious: who wants to talk about your own behavior if it's something dangerous or strongly condemned in your community? But the inventive staff of the Swasti Health Resource Center, Oxfam's research partner, came up with a plan and a new research tool, which they call the polling booth.
"Do you use condoms?"
Eight women sit in a circle, each with a cardboard box in front of her to conceal the choice of cards she places in a jar. In the center of the circle stands a facilitator who asks a set of questions aimed at determining how vulnerable these women are to contracting HIV.
This is a demonstration of the polling booth technique. The equipment involved is simple: a jar, a cardboard box, and a stack of numbered cards—green to indicate yes and red for no—are all it takes to build a "booth." But with willing participants—and researchers who have earned their trust—it can be used to carry out the very delicate task of eliciting honest answers to tough questions.
After the polling booth survey, the facilitator and participants tabulate and discuss the results. In a real-life situation, the facilitator might begin by saying, "Two people answered that they use condoms and six said they don't. Why do you suppose people in this village might choose not to use condoms?" Such a question could launch a valuable discussion of community perceptions of condom use and the spread of HIV—with no one having to reveal his or her own personal decision.
"What we share in a polling booth is fact," says S. K. Shashikala, who participated in the Swasti research and later helped demonstrate the technique to observers. "In this process, there is no inhibition."
Researcher Manoj T.J. led groups of men in these polling booth sessions. "The participants had a chance to talk about issues that they might otherwise be silent about," he says. "The discussion often revealed realities on the ground. When you know those realities, you can plan accordingly."
A research participant named Vasanthamma added a gender dimension: "This is good for women where we come from a culture of silence."
A wake-up call
Although the researchers were successful in their mission, they had bad news to report. After interviewing around 1,000 people in 30 tsunami-affected communities, they determined that in 10 out of 11 of the temporary shelter settlements studied, HIV vulnerability rose in the aftermath of the tsunami. (Read a summary of the report.)
The lingering trauma of the tsunami disaster combined with life in the crowded temporary shelter settlements and disruptions in employment triggered changes in sexual behavior which, in the absence of strong knowledge about safe sex practices, put men and women at risk. Strict community standards of behavior were unenforceable when villages were scattered into temporary camps, and many survivors were drawn to alcohol and extramarital relations—including commercial sex—as a means of coping with stress, boredom, and overwhelming grief.
Now that the tsunami recovery is well underway, many of the conditions that caused HIV vulnerability to spike have been resolved. The need for AIDS education and services remains acute, but most people can report that they've moved out of temporary shelters and are back to work, and that the trauma of the tsunami has subsided. But for emergency aid providers, the research has implications far beyond the coast of India.
"If aid providers don't supply enough water or food or shelter after an emergency, it's clear to everyone what's wrong, but a rise in HIV risk after a disaster can go undetected until it's too late," says Mike Delaney, Oxfam America's Director of Humanitarian Response. "Now we know much more about how responders in future emergencies can help communities reduce their vulnerability. This is research that could save lives."