Fellow Since 1994
This description of Quarraisha Karim's work was prepared when Quarraisha Karim was elected to the Ashoka Fellowship in 1994.
Quarraisha Abdool Karim is pioneering a gender-focused regional strategy to guide anti-AIDS efforts in Natal, the region in South Africa most affected by the epidemic. She has founded a comprehensive AIDS research program in the region, which is based on community participation and aimed toward causing preventative changes in behavior patterns. In 1995, Quarraisha was appointed to the Ministry of Health as National AIDS Coordinator.
The New Idea
Quarraisha Karim is launching a comprehensive AIDS intervention program that uses participatory research methods to develop an effective intervention strategy. Reaching a wide range of individuals, Karim 's program is concern about AIDS related issues for women, teenagers, prostitutes, migrants, and those in the rural community. Giving special attention to the disproportionate rate of infection among women, she is working to understand the nature and progression of the epidemic and the impediments to changes in popular behavior. She empowers disadvantaged communities to lobby for change by conducting studies to provide them with the necessary empirical ammunition. Quarraisha is also establishing a regional network to facilitate the flow of such information between key decision makers and health workers, with a focus on the transition between the populace's acquisition of knowledge and changes in its behavior.
There has been general recognition that efforts to prevent and control AIDS in the current pre-vaccine period need to focus on altering behavior to reduce the risk of HIV transmission. Both epidemiological and behavioral research are of critical importance in promoting the key components of these efforts, including monogamy or the limiting of sexual partners, treatment of sexually transmitted diseases, and the use of condoms. However, the complexities of South African society pose a major challenge to anti-AIDS efforts. While initiatives from the non-governmental sector are constrained by limited technical and financial resources, most people view initiatives from the government with suspicion. There is currently no national or regional plan of action to guide anti-AIDS efforts, nor has there been any attempt to bridge the gap between those that have the resources to curtail the epidemic and those who are most affected by it. Factors such as the migrant labor system, the associated breakdown of family units and conjugal stability, poverty, rapid urbanization, oscillatory migration and other challenges to traditional structures have contributed to the rapid transmission of the virus in South Africa. As in the rest of Africa, HIV is primarily transmitted heterosexually in South Africa. The position of women in society has increasingly been recognized as a factor in their ability to protect themselves from becoming HIV-infected, particularly in negotiating the use of condoms. Furthermore, a recent International AIDS Conference in Amsterdam recognized that HIV is transmitted 7 times more efficiently from men to women than from women to men. An anonymous population-based survey conducted by the South Africa AIDS program among rural blacks similarly demonstrated that women were infected with HIV at a rate four times higher than males. While new prophylactics that will allow women to take control are still being developed and tested, strategies to enable women to protect themselves must be identified. Therefore, the current challenges for AIDS research and intervention are to identify the impediments to changes in behavior and use this knowledge to develop appropriate intervention techniques.
Quarraisha has started a comprehensive AIDS research program in Natal/KwaZulu, the region suffering the worst from the AIDS pandemic. Her approach emphasizes consultation with communities through traditional structures, democratically-elected organizations and lay people. The community has a voice regarding how the research is conducted and elects representative members of the research team. All information is rapidly communicated to policy makers, the scientific community and the public through the popular media, medical and scientific journals, conferences, presentations and workshops. Quarraisha's multi-disciplinary team is using epidemiological, behavioral and anthropological approaches to providing information about the AIDS epidemic and to play a strategic networking function with key health workers throughout the region. This team conducted the first anonymous population-based HIV surveillance survey undertaken among rural blacks in Natal/KwaZulu, providing the most reliable insights to date on the epidemic and its progression in South Africa. This survey then served as the pillar on which the program developed its key focus issues: the disproportionate high rate of infection among women and people between the ages of 15 and 24, the association of AIDS transmission with a migratory lifestyle, and the need for surveillance. In order to understand why young people and women were at higher risk, several behavioral/anthropological studies were undertaken, some of which are still in progress. Quarraisha's community-based AIDS program currently includes twenty-five separate projects, with focuses on such topics as prostitution and family planning. Her study sites vary widely to include a rural community and an informal settlement, where traditional values are challenged by the migrant labor system and the impact of urbanization. She collects information on individual and community perceptions of AIDS and sexuality through group discussions, key informants, observation and in-depth interviews with both men and women. The interviews document what men and women know about AIDS, their perceptions of risk and of "rights", existing social norms, communication between partners, violence within relationships, decision making, economic dependence, and issues relating to group support and networking. The program uses a gender-conscious approach to examine perspectives toward behavior that protects against HIV infection. Another strategy to effect behavioral change focuses on condom use among teenagers. The program has targeted family planning clinics, the major distributor of free condoms in South Africa and a central primary health care provider. Interviews with family planning staff revealed that few had taken any initiative to include AIDS information in counselling their clients on fertility control. Recommendations emanating from Quarraisha's studies have already been implemented by the authorities and now AIDS information is provided by family planning staff throughout Natal. To ensure that its AIDS education and prevention efforts are sustained, Quarraisha's program identifies community liaison people and organizations. Through intensive informal and formal AIDS training, the community liaisons become key AIDS resource people in their communities, providing information and condoms. The community organizations have, through the programs' presence, started to incorporate AIDS messages into existing agendas and processes of development. Quarraisha is creating a directory of regional anti-AIDS efforts and developing a Regional AIDS Plan of Action using results from the investigations of diverse subcommittees over a nine-month period. The Regional AIDS Planning subgroup (RAPS) has initiated a process including a wide range of players, from traditional healers and religious groups to governmental and non-governmental organizations. Within six months, Quarraisha managed to include as active participants and financial sponsors influential government AIDS workers who had initially opposed her concept and actively obstructed the process. Today, RAPS is increasingly recognized as the most important national anti-AIDS initiative.
Quarraisha began her career as a scientific researcher, but was frustrated with the limited impact of her research. Driven by the need to "make a difference", she went on to pursue a career in epidemiology. Because there are no schools of Public Health in South Africa, both Quarraisha and her husband, who had introduced her to the discipline, trained in epidemiology at the Columbia University School of Public Health in New York under the guidance of ex-South African professors Mervyn Susser and Zena Stein. Shortly after returning to South Africa, Quarraisha joined the Medical Research Council, a statutory body conducting research in priority areas that affect the majority of the population. The AIDS crisis in Natal allowed her both to jump into the front lines and to explore the use of epidemiology as a tool for social change. Quarraisha has consistently sought to transform the researcher into a facilitator that can bridge societal gaps through attempts to control and prevent the spread of the HIV epidemic and to provide of care for those already infected. She is now beginning seriously to disseminate the information she has discovered. She has recently given keynote addresses on HIV infection at two major AIDS conferences in South Africa. She has also presented her work in Mozambique and Senegal.