The Newsletter of the World Health Organization Global Programme on AIDS ,
Year 1992 No 3, pp.15-16

An Interview with Zbigniew Halat

Dr Zbigniew Halat, an outspoken epidemiologist of 42, grew up and studied in the city of Wroclaw, close to Poland's border with Germany. Involved in the local organization of Solidarity in 1980-81, he left Poland after the declaration of martial law to study venereal and skin diseases in Kenya. From 1982 to 1984 he organized a free clinic to treat sexually transmitted diseases - STDs) in Nyeri, capital of Kenya's Central Province, where he saw patients with what he now believes were early symptoms of AIDS. After martial law was lifted in 1984, he returned to Poland to work in the public health system on allergies, skin disease and immunization. In the autumn of 1987 he launched one of Eastern Europe's first AIDS hotline counselling services, and since April 1991 he has been responsible for environmental health, disease prevention and control and the national health programme in Poland as a Deputy Minister of Health and Social Welfare. Despite considerable opposition, Dr Halat advocates (* see here revised position) condoms - not just abstinence - to prevent AIDS, and he is training an army of midwifery and nursing students to spread the message of safe sex to boys, girls and fellow teenagers of both sexes, partly through the use of educational materials from GPA. (WHO also assisted Poland in setting up its short-term plan on AIDS in 1990, and it is helping to prepare a conference to reach a national consensus on AIDS.) Dr Halat spoke to Global AIDSnews while on a recent visit to Geneva.

Dr Halat, how prevalent are AIDS and HIV infection in your country?

Officially there are said to be 2200 people infected with HIV, and 100 cases of AIDS. In both cases, about 70 per cent of them are attributed to drug abuse. I think all these figures are wrong. This is partly because male and female sex workers, and men who have sex with men, tend to get help in private clinics which have no procedures of notification. And there is a lot of misconduct in such places - people taking blood samples, for example, throwing it away and telling people they are uninfected. We need to strengthen our medical system and open it as much as possible to all groups in society. The true incidence of HIV and AIDS in Poland will bc seen only when we can fund a proper study and can organize a top-quality unit. We do not have what is needed to make proper diagnoses. We don't have the equipment to conduct a bronchoscopy, for example, to look for PCP. (Editor's note: Pneumocistis carinii pneumonia, a common AIDS related illness.) In my opinion, most transmission of HIV in Poland is through heterosexual sex.

If so, Poland would differ in this from other European countries. How do you believe this has come about?

It goes back to the 1970s, when the then communist government first allowed Polish citizens to travel to the West freely. Differences in the economic levels of neighbouring countries lead to prostitution and infection. And cheap sex brings with it an enormous danger of HIV. Living in Poland is like living in the Caribbean and being close to the USA. When Poles got the freedom to travel in the 1970s - I was earning $ 10 a month at the time - many of my fellow citizens went to Germany and sold sex to get money. Now, many people come here for sex. They pay girls and boys for unprotected sex. Young boys of 10 or 12 hang around outside buses from Germany offering sex for very little money. Unfortunately, there are men and women who find sex boring unless it is unsafe. And there are parts of western Poland where many young people go to Berlin to be prostitutes. Male prostitution is quite common, but not as common as female prostitution. Also, the spread of bloodborne diseases in our country is very dynamic.

One in 1600 Polish women between the ages of 20 and 29 get the hepatitis B virus (HBV) in hospital or outpatient clinics during their pregnancies. So HBV in Poland is more common in women than men, whereas in most countries, the reverse is the case.

Poland is heavily Roman Catholic. Does this pose problems for you in spreading the message of safe sex?

Religious problems are a real obstacle, a real interfering fact. According to Catholicism, a man should not deposit his semen anywhere other than in his wife's vagina, so sexual fondling and masturbation to ejaculation are out of the question. But we need to adjust our advice sensibly to reality. Promiscuity exists in Poland as it does in other countries, and you have to admit that sexuality is an issue for young people and cannot be seen only as a sin.

So have you run into problems with the Catholic Church?

If you say plainly that something endangers people, and if you repeat it enough times, thc Church has no objection. I say, let a priest be a priest, let a doctor be a doctor. But priests are not the only people who pose problems. In 1991, one of my fellow deputy health ministers said that condoms were only for deviants. He was fired by the prime minister of the time, Mr Bielecki, who was a liberal. And an education minister said recently that there was no need for AIDS education. I said his comment was "very exotic".

What is the position on AIDS education?

The older generation does not want to talk to another generation about sex. There are some things which most mums and dads find it impossible to say. Doctors are not good at AIDS education because they tend to medicalize the issue and use words of Greek and Latin origin. And teachers get red faces about condoms. In any case, in this time of transition from communism, when there has been a swing to the authoritarian right, it is not possible to incorporate AIDS education into the official curriculum. In my opinion the best way is to use peer educators.

Who will these peer educators be?

We have an army of young women - 13 000 secondary nursing students, 3000 of them doing midwifery - who could be health educators. We started a peer training programme in 1988 in Wroclaw with the headmaster of the local midwifery school. The midwife peer educators, who are usually 19 or 20 years old, go into local schools and talk to the pupils from the ages of 11 up, usually separating the sexes until they are 15. The system is now very well-known in the area. Other schools are asking for it, and parents too. We find that young women can talk about sex much more easily than young men with their peers, male and female. The educators tell the group that it is natural for young people to have sexual urges, to masturbate, and to fantasize. This gets them all relaxed. And then the educators come in with the message: "But when it comes to intercourse, use a condom and/or a virucide". And they tell the girls it is important to know someone for more than one day, and that they should check whether the boyfriend can fulfil his role not just as a sex partner, but as someone they can talk to and enjoy other leisure activities with. One aim is to delay first intercourse. I follow the idea of abstinence as an ideal, but at the same time realize that it can be too demanding.

How do you plan to mobilize the whole army of nursing and midwife students?

We have set up a programme called Sami Sobie - "Ourselves for Ourselves". It is headed by Dorothy Czyrek and Ivonne Mackiewicz, who were in the first group of peer educators. We hope to make a short-cut to a new generation of Poles using self made educational materials based on WHO and Red Cross models. Fifteen girls from Warsaw and Wroclaw went to Bristol in June to learn of British experiences, and with WHO support we organized summer camps for 60 midwifery students and 60 nursing students in August to train them as trainers to go into the schools. They will go into the schools and show how to use condoms by putting them on their fingers, and so on. (I do that whenever I go on television.) The girls will also talk about general health promotion, including what tobacco can do to you, not just about AIDS and sex. The Polish population is dying from smoking and drinking and lack of physical exercise.

What about condom supply in Poland?

For many years, there was a factory in Poland which produced condoms with holes and measured their elasticity with rulers. Now we have founded a new Polish-German joint venture with quality technology looked after by German specialists. We make all kinds of condoms, even flavoured ones, for oral, vaginal and anal sex. And they cost the equivalent of 18 US cents for three.

If your plans for peer education come to fruition, the younger generation will be well educated on AIDS issues. What about the generation of people who came before them?

Opening statement, by Zbigniew Halat, M.D.

It gives me great pleasure and it is an honour for me to welcome you to Poland, to Warsaw and to this workshop on AIDS hotlines for countries of central and eastern Europe* The workshop is convened in collaboration with the World Health Organization» the Ministry of Welfare, Health and Cultural Affairs of The Netherlands and the Ministry of Health and Social Welfare of Poland, and organized by the Dutch National Committee on AIDS Control.

I understand that this is the second such meeting in Europe, and the third in the World, organized with financial support from the Dutch Government. I wish to express my gratitude to the Government of The Netherlands for their commitment in this respect. I also want to put on record my ppreciation of the fact that so many participants from the countries in Eastern and Central Europe have been able to come together here, in spite of all the practical difficulties we know most of you experience at present. Some sixty individuals from countries in central and eastern Europe have gathered here today including facilitators and temporary advisers from seven Western European countries.

The tremendous interest to participate in the workshop is an indication of the correct decision of the Global Programme on AIDS in the WHO Regional Office of Europe to give priority to the planning and development of AIDS hotlines in countries in central and eastern Europe.

This is a field where a tremendous amount of experience has accumulated recently in countries in western and northern Europe over a relatively short period of time. There is need to share knowledge of the success and the failures that has been gained, so that we in the countries of central and eastern Europe may profit by the experiences in western and northern Europe, and adapt your knowledge to our own realities.
<>It is often said that, at present, the only vaccine we have against transmission of HIV infection is information and education. However, the AIDS pandemic has underscored what we have known for a long time; that not every form of information influences people, increases knowledge, changes attitude, or makes a difference in changing behaviour. The AIDS pandemic has taught the world that there are great differences between old-fashioned health propaganda and the modern social marketing that is part of health promotion. It has illustrated the importance of target groups having confidence and trust in the source of the information. It has underlined that representatives of target groups should have a say in how their peers should be approached. It has shown the total superiority of one-to-one transfer of information in a counselling setting, and targeted campaigns should not be discounted as important consciousness-raising elements of a total information, education and health promotion strategy in HIV/AIDS prevention and control- However, before we start attempting to transmit information to achieve behaviour change, we must learn how to communicate effectively in a counselling situation.

Counselling in any setting demands listening skills and empathy. Helpline counselling by telephone requires special skills. These skills do not come naturally to most of us; they need to be learned.

When a person has overcome his or her reluctance to call an anonymous telephone number and to start to talk to a stranger about sensitive issues like HIV/AIDS, sex and drug use, they do not usually want to be met by a person spewing out series of epidemiological statistics or masses of biomedical facts. What they want to meet at the other end of the telephone line is a sensitive, empathie person with active listening skills; a person with ability to guide the caller to decisions that are right for her or him.
< style="font-weight: bold;">Various ways have been chosen in various countries and different settings to meet the needs and demands of the hotline callers or "customers". In some cases great stress has been put on the counsellors with professional training in health or social sciences or services. In other cases the stress is on volunteers with non-professional backgrounds; simultaneously stressing the need for the helpline to enable the non-health (or social service) professional to be really a professional counsellor rather than a counsellor with a professional background» and achieving this through intensive and extensive training» and on-the-job supervision.

Participants at this workshop will have the possibility to discuss the pros and cons of various solutions to a number of challenges and problems that have accumulated over the years of running AIDS helplines and other specialist telephone hotlines in western and northern Europe.
< style="font-weight: bold;">In this, let us remind each other, however, that the solution we choose for our own ventures must build on acknowledgement of the cultural and traditional sensitivities that are peculiar to each group targeted* Such sensitivities exist and need to be recognized. Breaking down social, legal, cultural, religious and traditional barriers may be needed concerning sexuality, sexual orientation and sexual practices, as well as concerning illicit use of alcoholj drugs and other substances. But in breaking down these barriers we must be willing to acknowledge that they exist and respect them for what they are, and on the other hand not be over afraid of breaking taboos. The very fact that there exists in the countries of Europe such variety of social» legal» cultural» religious and traditional attitudes is in itself one of the things that make Europe an exciting continent, and with increase in personal liberty in so many -more countries» even more so at present than a few years ago. However, in.relation to the AIDS epidemic the very expressions of freedom paradoxically..put the population at risk calling for a firm public health and social policy response with concerted action of voluntary activities and statutory actions and duties.

There is an impressive array of participants and of advisers at this workshop. I am convinced that together you will be able to find answers on how to respond to this paradox of personal freedom and health-endangering behaviour. You will not give us the ultimate answer, but you cannot fail to give us important guidance. I wish you every success in your deliberations.

While the world wasn't looking, Eastern Europe's regimes poisoned their environmet in the name of progress. Now new leaders must assess the damage and set priorities for reversing it.

In the fall of 1989 the communist governments in Eastern Europe began to crumble. As the Iron Curtain was torn apart, journalistst - nosing around in Poland, East Germany, Czechoslovakia, Hungary, Romania, and Bulgaria with a newfound freedom - were met by an outpouring of complaints about polluted air, contaminated water, and poisoned soil.

The headlines in the Western press - "Pollution Chokes East-Block Nations", "Environmental Catastrophe in Eastern Europe" - brought a crowd of questions to my mind: Why all the fuss right now? How bad is it? How did it happen? Is it affecting people's health, and how are the new governments responding?

(...)

Now that the Eastern block has opened up, the most outdated, inefficient, and uneconomical factories - often the worst polluters - will simply disappear, and thousands will find themselves out of work. With massive unemployment and backward industry, it will be almost impossible for any governments to make the environment a top priority.
Because pollution was used by political activists as a stick to beat the ruling communists and because money and jobs are far more important to the man in the street, the pollution issue will likely fade from the headlines. The sewage and sulphur dioxide, however, will still be there. To achieve the standards we take for granted, huge sums of money will have to be spent. But whose money? How will Eastern Europe's struggling economies pay for the necessary improvements, let alone the clean technologies we are now beginning to expect?

Enormous tasks lie ahead. To tackle them, East and West must join together. But will Eastern Europe's new rulers find the environment as important now as they did when they were in the opposition?