Berkley Center

Background: Peter Okaalet has thorough experience with the HIV and AIDS pandemic, both as a physician and a theologian. He has thus witnessed the evolution of thinking and practice and the impact of this disease on both society and church. In this discussion with Crystal Corman in Nairobi on April 10, 2015, he reflects on his own path and the importance he attaches to ensuring that pastors are knowledgeable about the disease and its impact. Curricula he has developed are now in common use. In his opinion, the recent devolution of health services in Kenya is an important and complex step, with advantages but also challenges.

To start with, how did you become so deeply involved in Kenya’s health issues?

In 1988 a young man, John, died in my hands with complications of HIV/AIDS. I was working in a hospital in Uganda as a medical practitioner. He challenged me, “If I were you, I wouldn’t do more degrees in medicine, I would go and do theology.” I asked why? “Because all of us are going to die someday, but if indeed there is another life up there, I don’t want to miss that life because now this one is ending.” Four days later, he died. I think he knew how he had contracted the virus so he was dealing with issues of forgiveness, issues of another life, and issues of just coping with the pain.

That challenged me (and continues to challenge me to this day)—that my medical training up to that point was not helping me. In Uganda in those days, we didn’t have antiretrovirals (ARVs), the medication that is now prolonging people’s lives. So I just watched him and prayed with him until he passed away. That kept going through my mind—how could I have helped him? Was there something else I could have done? So I took up the challenge of doing theology. My wife and I crossed the border to Kenya in 1990 (two and a half years later). We came to study theology at the Nairobi Evangelical Graduate School of Theology. It’s now Africa International University. We haven’t gone back to Uganda since then, except for visits to family members, and when necessary.

What was your focus as a student of theology?

Upon completion of my master of divinity in 1993, the college asked me to be the medical doctor of the college, which involved looking after the lives of students, their families, faculty, staff members, and so on. But I had my mornings free, so I asked them to support me to do another master’s degree. I did a master’s in theology on the relationship between husbands and wives. Within biblical studies I chose to focus on husband and wife relationships, specifically headship and submission. Submission is a very sticky word. So I focused on what is in the Bible about what women should do and what men should do.

I didn’t reject the word submission because it is Biblical. It is difficult to rub it away but we can understand why it is there. When you start by understanding submission is meant to be mutual, it makes it a little easier to talk about wife submission, roles and responsibilities. Then the challenge for the man is to love his wife like Christ loved the church, willing to die for the church. That’s where many men fail. When it’s convenient for them they will talk about submit, submit, submit. Then when it is not they will shift to ‘my culture says this.’ Africa is a hierarchical society, so it is cultural for man to be above girls and women.

How did this theology expertise blend with your health work?

When I completed these studies, MAP (Medical Assistance Programs) International was looking for someone and I was hired after graduating with my second master's in 1996. From 1996 to 2011, I worked with MAP International at the East Africa region level, the continental level, and then the international level. From 2002 to 2006 I was Africa director, then 2006 to 2011, I worked in the global role as the senior director for Health and HIV/AIDS Policy for MAP offices in Latin America, some here in Africa, and in the U.S. in Atlanta, Georgia. By God’s grace, I even addressed the U.S. Senate (in February 2003) on the role of faith-based organizations in the fight against HIV/AIDS.

How did you get involved with HIV/AIDS in the first place?

Uganda used to be at the top of everybody’s lists because the president was really at it. They had the best response—openness, welcoming, compassionate, and talking about it. We started responding to HIV/AIDS in 1986. I was trained in 1987 for pre-test and post-test counseling.

There was an organization that was created by Noerine Kaleeba—TASO, (The AIDS Support Organization). Her husband passed away due to complications of AIDS through a blood transfusion; the blood was infected. He was flown to the U.K. for treatment but, long story short, he succumbed. Three months later, she decided to do something about this disease and worked towards preventing other people from catching it, especially women. So Noerine created that organization. She started training people who were willing. At the time, I was working in eastern Uganda and she was based in Kampala. Their team came to our region to train those of us interested in learning. That was my initial involvement. TASO reached out to religious groups, churches, pastors, and bishops. Then one of the Anglican bishops, Bishop Misairi Kauma, lost his son also around that time.

Were churches and faith leaders open to getting involved in HIV/AIDS?

When Bishop Kauma was told his son died of complications of AIDS, he reflected on the use of condoms and the roles of church leaders and so on, especially on the Catholic Church opposition to condoms. He asked himself after three to four months, “Suppose that my son had protected himself that night, the night he got the infection. Perhaps he would not have been infected.” So he coined a phrase when he was talking to young people. “If you are going to be so foolish enough to engage in pre-marital sex, don’t be so stupid as to not protect yourself.” He did not mention the "C" word, but at least the message went home to young people.

Because of his activism, the president of Uganda made him the chairman of the National AIDS Commission (NAC). Here in Kenya it’s called the National AIDS Control Council. From that point on it has been headed by religious people. If it is not a Catholic bishop, it will be an Anglican bishop, or the leader of one of the other main religious groups as chair. President Museveni realized there is something about religious people. They have a big following, and when they speak, people listen. They are very influential, as I’m sure you have found.

So would you say this is part of the reason that Uganda’s response was so strong?

Its response to HIV/AIDS was very strong, but in those days we were not talking about strategic planning with a national strategy. The president led the way and leaders below him, like the bishops and carried the agenda. Eventually when the prevalence rates came down, the researchers came and asked what we had done. Initially I think the response in Uganda was just ad-hoc. People were dying in southwestern Uganda. Those who died were the parents and young adults, so children were now heads of households. When a community noticed this, they had to pull up their socks and do something about care and behavior. Only later did plans and strategies emerge, as countries sought external financial support.

Apparently over the years the leadership [of Uganda] has deviated to other areas so we see the focus on HIV/AIDS is really going down. While other countries used to go and learn from the experience of Uganda, now people are coming to Kenya. People from China and India, from other places, come to Kenya because Kenya seems to have got their act together and the prevalence is much lower now than even Uganda. The national average in Kenya is about 5.6. But in some regions it is much higher depending on the behaviors of the people, culture, social practices, etc.

Why do you think that Kenya is doing so well? What do you think they’re doing right?

A main factor is that the leadership is in place. The National AIDS Control Council in Kenya is the coordinating body. When it was created, they developed two documents: a monitoring and evaluation framework and then a strategic plan. They talked about the Three-Ones—having a coordinating body, a strategic plan, and a monitoring and evaluation tool. Then you can begin to put your arms around the response to HIV/AIDS.

Recognizing the role of religious leaders has been important; the Council is working together with religious leaders very closely. I have been invited to support here and there the development of the National AIDS Action Plan and the National Action Plan by faith-based organizations. While we have focused on the national response, the government is now devolved politically so now we have 47 counties plus the national plan.

So devolution also includes the health system?

Everything is included. It is a challenge to devolve health, including the doctors, the nurses, and staff. There have been reactions and some problems such as doctors going on strike, people unattended and dying, nurses going on strike because they did not want their salary to come from the county. They wanted to be paid by the national government. They felt remaining with the federal government was better for their career.

The Ministry of Health has had good discussions with several of the governors in terms of approaching the challenges. The process has not gone very smoothly. It’s very complicated. Kenya has medical groups and the churches also have hospitals. I think over 40 percent of the response to challenges in health is through faith-based organizations and the government recognizes their importance. The Protestant churches have the Christian Health Association of Kenya (CHAK), which is quite involved and the Catholics have an equivalent, the Kenyan Episcopal Conference, now known as the Kenya Conference of Catholic Bishops (KCCB). They are working together. MEDS (Mission for Essential Drugs and Supplies) is coordinated by the KCCB and CHAK; they handle pharmaceuticals for some of the UN bodies, CDC and even PEPFAR with the ARVs and so on.

Tell me more about the Kenya national strategy and if or how faith-based providers are involved?

Nationally there is a Kenya AIDS Strategy Framework. The government has asked the faith-based organizations how they plan to fit into this. A meeting was held in Nakuru at the end of March 2015, to discuss how the faith-based organizations respond to that at a national level but also at the county level. At the moment, they’re trying to identify (faith leaders) champions from each of the counties who will then work together with the National AIDS Control Council (NACC). The NACC recognizes that approximately 95 percent of this country professes some kind of faith and therefore they are working to have a desk for faith-based organizations. That way, they will work with the Ministry of Health, universities, the private sector, and several other groups that are similar to faith-based organizations. If indeed they partner with faith actors, building their capacity and especially documenting what they are doing to share with the government, this will go a long way towards realizing the goals of the framework.

Kenya, it seems, has been involving faith actors for quite a while.

Yes, a long while. But there are still gaps. If you are doing four things very well, (Peter holds up four fingers), there are three gaps—three things very well, there will be two gaps. We need to partner with others who face gaps to strengthen each other. In all these countries they are discussing issues like how to get the religious people involved, whether it’s in reconciliation, gender issues, peace building, HIV/AIDS. I think there are more religious actors who speak up in this part of the world. It’s very key.

I will be one of 90-plus leaders who’ll attend a PEPFAR consultation (April 2015) on the role of faith-based organizations in sustaining community and country leadership in the response to HIV/AIDS. It is to follow-up with those faith-based organizations that were invited from Kenya, Uganda, Rwanda, and Tanzania two years ago. They want to know what different things have been done, how have they used the recommendations? We’ll continue to sustain this response by faith-based organizations for HIV/AIDS. Emory University is involved, as well as PEPFAR, and CDC.

On HIV/AIDS, where is Kenya now? Where does the most focus need to be?

The young people are most affected. Those between 15 and 24 are dying more of AIDS than any other age group. It seems we focused on adults so much that we forgot that group.

Kenya has developed a Kenya HIV Prevention Revolution Road Map, count down to 2030. The aim is to focus on ‘Cluster A’ Counties, with an HIV prevalence of between 10 and 28 percent. These are Nairobi, HomaBay, Kisumu, Siaya, Migori, Mombasa, Turkana, Busia, Kissi (Kenya HIV Prevention Road Map, by NACC and NASCOP, 2013).

How do faith-based organizations work with that group if they are unmarried?

Faith communities must use the structures they already have, whether they are Muslim or Catholic, Christian, Protestant. If you have Sunday school or youth group, how can you talk about relationships and HIV/AIDS prevention?

In my church, we have a ROPES (Rites Of Passage Experiences) curriculum that Christianizes rites of passage from child to adulthood, hoping to make rites and rituals safe, involve the parents, and teach about what it means to be a woman, what it means to be a man.

What can you tell me about curriculum or training for faith leaders on health topics like HIV/AIDS?

For HIV/AIDS, we recognized that many of the pastors didn’t know how to go about addressing the issue in the congregation. So we thought that we needed to come up with a curriculum targeting theological institutions, Bible schools. The goal was that before these pastors graduate and before they are sent out to minister, at least they will have gone through HIV/AIDS training. We started with manuals and came up with something called Choosing Hope, with eight modules. It dealt with various aspects of hope. That’s for people who already graduated and are working in their churches, like refresher courses.

We saw that this was not enough, so decided to go into the institutions. We (at MAP International) developed a strategy called HIV/AIDS Education in Theological Education. We worked with St. Paul’s University in Limuru. Now they are running programs at undergraduate level, and at master’s degree level. At the M.A. level, it is the Community Care and HIV/AIDS program. The first class graduated in 2006. Once the curriculum is in the school then all the students going through that school can benefit. Students can choose to sign up. The core course is theology and then there are electives. But in the end, everyone has to go through it. I think it became mandatory. St. Paul’s picked it up first. Lately, several other schools in the region like, Uganda Christian University, picked it up.

Also implementing the M.A. level curriculum—with contextual modifications—are Makumira in Tanzania, Kwazulu Natal and Stellenbosch Universities in South Africa, Evangelical Theological College, in Ethiopia.

Has this training for clergy been effective?

Unfortunately we don’t have the funds to follow through with, for example, a cohort study where you compare congregations run by people who have gone through that course and another as a control. Anecdotally, though, we can see that there’s a lot of difference. I’ve visited and worked with some of them. It’s exciting to see what they’re doing. Some of them are asking for Ph.D. and the master's level courses. It makes a big difference when we follow that model in terms of understanding, responding, prevention, care, and support.

What are the main HIV/AIDS issues in Kenya today? And do you see far less orphans as a result of AIDS?

If you compare the population of adults on treatment to those that are diagnosed with HIV, and those who need the treatment, the population of adults on treatment is bigger than the population of the children. Pediatric AIDS is still a challenge. Another challenge that is coming up is children who are born with HIV whose parents died, who are growing up as teenagers and young people. There you cannot talk about prevention, yet they need to be taken care of. But they are now at the point that they are getting into social relationships, so how do you handle that? This is a challenge not just for Kenya but for the region.

Some groups focusing on this group: the clinics and hospitals run by Africa Inland Church, like Kijabe Hospital. They give them the medication and treatment, and they report regularly for checkups. But who is addressing the psychosocial issues these young people have? I want to do something about that—and/or partner with others doing the same. And I’ve considered writing a book on the subject.

So there’s still a lot of work that needs to be done?

Yes indeed. When I hear about an AIDS-free generation, I think it’s just a statement. We can hope to stop new infections or reduce them sharply by 2030, as in the strategic plan. That is a goal that can be achieved. But in terms of an AIDS-free society, I think that is a little too ambitious, because of the number of people infected will continue to go up. Now retired or elderly people are starting to contract HIV/AIDS because of their life styles—and the elders have kind of been left out of programming. Men, when they pass the midlife crisis, want to prove something. So apparently there’s a spike among that generation that is getting infected.

Do you think all the awareness raising will have a lasting, life-long impact? Or are people forgetting about the risks?

Uganda is the only country in the region where there is resurgence. All the things we talked about were done, for example bishops and everyone responding. For a generation, few of them have died. But I think they are just worn out. So I think we just need to keep retraining generation by generation. Otherwise people become complacent. Now that we have ARVs, people know they can take their medication and continue to live normally. This is in itself a challenge because people now view HIV like hypertension or diabetes—I can live with it, so what is the big deal?

What are some of the sticky issues for religious leaders in terms of engaging on HIV/AIDS work?

I’ve done trainings with religious leaders across denominational divides. In one meeting a Catholic bishop said, “Surely you don’t expect me to hold the Bible in one hand and a condom in the other hand and give it to the congregation? Is that what you expect me to do?” I responded by saying that from the pulpit in church, I will leave that to the Bible. But after mass, in a one-on-one meeting, you can offer to talk about how each individual needs to protect him/herself. Some of the bishops have come a long way to appreciate the fact that they may not distribute condoms but they just need to work with everybody who needs to be protected. Whatever their lifestyle and whatever they’ve chosen to do, they need to be protected. Some religious leaders are outspoken and they can be approached. Some are not. People learn who can be approached.