HIV/AIDS Action research in Cambodia
SOME UNEXPECTED RESEARCH CONSEQUENCES OF A RE-ENGAGEMENT
WITH THE HISTORY OF SOCIAL PSYCHOLOGY: LEWINIAN (1946) ACTION
RESEARCH AND THE CURRENT CAMBODIAN HIV/AIDS CRISIS. (1)
University of Guelph
and Mee Lian Wong
Department of Community,
Occupational and Family Medicine,
National University of Singapore
As Kurt Lewin's (1946; 1947) innovative "action research" studies (Cherry & Borchuk, 1997) have led to recent work involving culturally sensitive "Participatory Action Research" (Chataway, 1997; Kral & Minore, 1997; Selby, 1999; Fine et al, in press), one of the authors (IL) came to re-appreciate it primarily through historical and epistemological critiques of social psychology (Lubek, 2000; Stam, Radtke & Lubek, 2000). The second author (MLW) had been making use of principles of action research in a series of interventions in Asian settings to facilitate public health and reduce the spread of sexually transmitted diseases including HIV/AIDS (Wong, 1990; 1991; Wong et al, 1999a). A series of in-depth interviews conducted in Siem Reap, Cambodia-- initially about surviving genocide and later risk taking-- revealed additional community concerns. With 200,000 tourists expected at the Angkor Wat temples this year, the 140,000 citizens of Siem Reap face an alarming HIV/AIDS epidemic, with 10,000 already sero-positive. Interviews indicate that amidst much inebriation, condoms were not being consistently used by young women who provided sexual services to both tourists and local men. Most of these "indirect sex workers" are "beer girls", employed by international companies (Heinekens, Stella Artois, Budweiser, Fosters, Labatts, Alain Delon, Becks, etc.) to sell monthly quotas of beer; these women, after drinking with their customers, were at greater risk for HIV/AIDS, as were married women whose husbands visited the "beer girls". Both groups of women lacked strategies for 100% condom compliance. Based on this feedback, a peer-educational intervention project was designed; materials successfully used in Singapore and Malaysia (Wong et al, 1999 a,b) were translated into Khmer and tested in focus groups, prior to broader distribution. Various measures of condom compliance are being piloted under challenging field conditions, and community meetings were held concerning creation of an all-in-one "Wellness" clinic for HIV/AIDS prevention, education, acute care, diagnosis, treatment, long-term care and follow-up.
Two separate disciplinary pathways to " Action Research"
The present project, addressing current social and health crises in Siem Reap, Cambodia, involves a collaborative, multi-disciplinary approach between the two authors, local citizens and health workers, government agencies and officials, local and international Non-governmental organizations (NGOs), funding organizations such as the Elton John AIDS Foundation, and a panel of international consultants in a broad range of disciplines. Eventually, it will need to also engage the co-operation of various local industries and inter- and multi-national commercial interests to sustain over the long term any positive impact of the current project on the local health situation. The two authors have combined divergent backgrounds to find common ground in social psychologist Kurt Lewin's "action research" model for social research and social change, which he outlined shortly before his death (Lewin, 1946, 1947). One author, Mee Lian Wong, came to action research quite directly through clinical and educational work in public health, designing programmes and strategies to reduce health risks and sexually transmitted diseases (STDs) both in urban and rural settings (Wong, 1990, 1991). The other, Ian Lubek, first came to appreciate "action research" from an "armchair " perspective, after critically analyzing the historical, epistemological and experimental underpinnings and shortcomings of social psychology (Lubek, 1997, 2000; Stam et al, 2000). In work with Febbraro and others, the history of the post-World War II Social Psychology programme at University of Michigan, was critically examined. Some of the important mentors there were affiliated with the Research Centre for Group Dynamics, and had been students and/or co-workers of Kurt Lewin's at MIT prior to his death. It was noted that many of the women preferred applied and action research studies, compared to a matched group of men PhDs who tended to do more experimental work in the laboratory (Febbraro et al, 1997; Febbraro , 1997). There was also a sharp criticism of the version of experimental social psychology developed by several generations of neo-Lewinians (e.g., Lubek & Stam, 1995; Stam et al, 1998; Stam et al, 2000). As a result, consideration was given to some of the social psychological "roads not taken", including Lewin's neglected blueprint for a more politically engaged and emancipatory type of applied social and community work. This "action research" perspective for social change continued to be practised by a small number of Lewin's former students and colleagues (especially those at the Commission on Community Interrelations, cf. Cherry and Borshuk, 1997) but generally seemed not to receive much attention in the textbooks. The relatively infrequent use of action research has been noted and Sanford (1970) talked about its demise as U.S. federal funding policies in the 1950s favoured basic research over applied. And for post-Lewinian action research, there may have developed several distinct variations (Peters & Robinson, 1984). In fact, one modern version gained increased multi-disciplinary adherents in the past two decades as "Participatory Action Research" (see for example, Chataway, 1997), (2)
Lewin's own written descriptions of action research are either somewhat informal (1946) or inter-twined in heavy theoretical and meta-theoretical discussions (1947) (3). Howver, one short section on "Feedback problems of social diagnosis and action" (1947, pp. 147-153) and a related diagram (Fig. 3, p. 149) do provide many of the ideas that would later be described as "Lewinian action research".
( Lewin, 1947, p. 149)/
Fig. 3 shows the multiple feedback loops in the action research project where, for example, "Reconnaissance of results might indicate change in general plan" (p. 149). Other colleagues and readers of Lewin, including the present authors, have taken out salient aspects of Lewin's descriptions and updated and/or rephrased these ideas in contemporary methodological terms, stressing the more democratizing, joint participation of community members and researchers in the design and interpretation of the research study ( see Argyris's, 1975, discussion of Model 2 research) , the feeding back of the results to the community participants, the redesigning of methods or theory (or the "general plan") in light of on-going joint discussions of the results.
(Chataway, 1997, p. 753)
Cynthia Chataway's version of Participatory Action Research (PAR) , as shown in Fig. 1 (1997, p. 753) starts with an immersion in the community and information gathering before any problem definition or research questions are attempted. Her discussion also deals with the problems of developing increased cultural sensitivities between participants and researchers. (4) And Michelle Fine and her co-researchers well describe this newer PAR, while still remaining faithful to the Lewinian roots:
Participatory action research represents a stance within qualitative research methods; an epistemology that assumes knowledge is alive, rooted in social relations and most powerful when produced collaboratively through action. ...[PAR] has typically been practiced within community based social action projects with a commitment to understanding , documenting and/or evaluating the impact that social programs, social problems and/or social movements bear on the lives of individuals and communities. ...at its core it [PAR] articulates a recognition that knowledge is produced in collaboration and in action." (Fine, et al. p 1)
In our own use of the term "action research", we believe that the research and intervention ideas we bring into a community must be modifiable, and even discardable, after discussions, interviews, focus groups within the community. The prioritizing of the action goals and the questions to be resolved through the research intervention will also primarily depend on the community members' perspective. The role of the external researchers should be research-degradable, starting out with a role of facilitation, networking, financing, and initial consultations on research design and actions, but eventually totally ceding their place to local participants who become self-sufficient community researchers.
From accidental tourist to action researcher : Serendipity and a community health action research project
En route to a Sabbatical stay in Australia, one of the authors, IL, made a three day tourist stop in Cambodia , to see the Angkor Wat temples, built at the former Khmer capital between the 9th and 12th centuries..
The kids at Angkor Wat sell postcards and mementos to tourists, practice their English, and all want a CD as a gift (except one who prefers a Mercedes). One report (2000) suggests 70% may have been propositioned by sexual tourists.
Here, a chance encounter occurred with a young man orphaned and uprooted during the Pol Pot genocide who talked about his precarious life, which included both career upward mobility, but also dangerous risk taking with heavy daily drinking, and weekend partying involving unprotected sex in the midst of a local HIV/SAID epidemic:
" There's only me and my grandfather left now-- my parents and family all died during [the 70s].... I've never had a wife .... Sometimes I would go home, drink 20 or 30 beers a night, and on the weekends we drink and party with the girls. We know we should use condoms, but sometimes with all the beer, we just forget... Monday it's back to work. Each week now, we bury one of our friends, who has died of AIDS or of one of the complications. There's no medication here...you get sick, even malaria, you go home and you die in a week or two. " (Anonymous male, Siem Reap, Personal communication, Feb., 1999).
In this one summary statement was to be found a whole set of issues which might fall under the domain of the applied social psychologist -- surviving genocide, alcohol abuse, risk-taking, HIV/AIDS prevention, gender relations, health-care delivery improvement, as well, as an implicit statement or subtext that this situation needed change. This statement thus helped propel one of the researchers from accidental tourist to action researcher. But could one brief interview reliably describe the entire town's situation? It was decided to systematically interview other citizens about these issues, focussing on the relationship between past trauma and current risk-taking. (5).
Prior to the Khmer Rouge 's taking of power, there had been internal fighting among different political factions, all set against the background of the expanding conflict in South East Asia in the 1960s and early 1970s, and a period of US bombardment. Immediately after seizing Phnom Penh in 1975, the Khmer Rouge implemented a policy of forced migration of the entire population to the countryside. During the next 4 years, it is estimated that about 1.5 million Cambodians (more than one quarter of the population) died, while millions of others suffered the effects of enforced, slow starvation. This genocide and uprooting in turn contributed to the breakup of Cambodian family and social life, as almost all Cambodian families lost relatives during this period. and all social and educational institutions (education, health care, law) were decimated by the targeted killing of all intellectuals and "people wearing glasses"; some managed to escape into exile (6).
As Cambodia rebuilds, primarily with foreign aid, the tourist industry has been seen as one source of income. The temples of Angkor Wat , connected by direct international flights to the town of Siem Reap, are expected to attract 200,000 tourists to a town which has a hotel-building boom, a population of 140,000 and 10,000 HIV/AIDS seropositive persons. The last decade has seen two forms of tourism rapidly developing: Cultural tourism to the temple monuments and sexual tourism to Siem Reap's nightlife of brothels, discotheques, beer-restaurants and Karioke clubs, often involving under-age teenagers, and almost exclusively, for the moment, women. (7)
There is a certain irony about the arrival of both HIV/AIDS and sexual tourism in Cambodia, co-incident with the arrival of the UN peacekeeping force in the 1990s; Siem Reap interviewees reported that the construction of discotheques, beer-serving bars, and brothels quickly followed the soldiers' arrival; today, some UN agencies such as UNAIDS and UNICEF help to battle the HIV/AIDS pandemic. (8) In addition, upwardly mobile young men, earning money in the tourist industry, could now also afford to participate in the life of drinking, discos and sex-for-money. The reporting of HIV/AIDS statistics by the government began in 1997 and some public education programmes via television and the schools also began, especially in Phnom Penh (Tarr & Aggleton, 1999). In Siem Reap, HIV/AIDS began spreading in the community, to wives and partners, and to newborns: by 2000, most of a sample of 19 persons interviewed in depth could now name personally someone in the community who had died of HIV/AIDS or related illnesses. In 2001, all 15 beer-girls interviewed could name fellow beer-girls who had recently died. Although the Cambodian government announced in May, 2001 that overall, the HIV/AIDS epidemic was decreasing, a United Nations report released June 20,2001 indicates that 2.8 percent of Cambodian adults and 2.6% of pregnant women are sero-positive; for the town of Siem Reap, the figure is 10% of the total population, and 5% of pregnant women, with estimates for the sex-workers ranging among 19% to 39.3% HIV positive in a 1997 government health survey, with one recent journalistic account suggesting 55%.
Community action research: Several beginnings
Using a combination of historical and psychological methods, one author (IL) conducted in February, 2000, a series of in depth, semi-directed interviews, trying to have citizens describe their life experiences during the genocide period , their current life style, including risk-taking and sexual activity in the face of the HIV/AIDS epidemic, and finally discuss their views of the future in Cambodia. (9) This combination of oral history, life history narratives, and clinical interview, offered a composite local view of the state of the community, its members, and some of the community's own priorities for future change. Using the action research (Lewin, 1946, 1947) format, a summary of the results of these interviews was fed back to the participants who agreed to form a grass-roots social-action group to address social, educational and medical needs in their community. (10) Nine persons joined the discussions at this time. (11) A year later, the second annual meeting of this local NGO was held, and 26 persons attended, an executive was elected, a bank account opened and discussions took place about further educational and medical interventions needed.
Based upon suggestions in 2000 from the community members, two specific vulnerable groups of women were targeted by the two authors in February and March, 2001 for an HIV/AIDS peer educator programme. (12) Materials previously successful in campaigns in Singapore and Malaysia to eliminate HIV/AIDS and sexually transmitted diseases such as gonorrhea (Wong et al. , 1999a and b), were translated and adapted for Khmer women . (13)
Translation discussion with Ian Lubek, Chew Keng Lee, Chivvy and Sophea.
Original booklet used in Singapore Khmer version of booklet
These were designed to offer practical and successful strategies for negotiating condom compliance by two groups of women at risk: the "beer-girls" and the wives of local men who frequent them. The "beer girls" were young indirect sex workers selling quotas of international brands of beer: Fosters, Budweiser, Stella Artois, Heinekens, Labatts, etc.
Young, often underage and illiterate, some were sold by their families to recruiters, and enter the sex-work arena without information about HIV/AIDS (and sexually transmitted disease) prevention.
Ian Lubek and Mee Lian Wong (middle) talk with 3 Siem Reap beer girls. Research assistant Sok Huor Chea interviews Heineken's beer girl, Phnom Penh. Research assistant Mok Vanna talks with 3 Siem Reap beer-girls (including one from Labatts Ice). 2 Davidoff Cigar girls , Phnom Penh.
Some sexual tourists often specifically request unprotected sex with the younger beer-girls, in the belief they are less likely to be sero-positive. These beer-girls, wearing the costumes supplied by the distributors, use "playful" sexuality to sell their beer for anywhere between $1.50 US and $4.50, depending on brand. They are paid $2 per day and sell about 24 cans of beer per day, and between 15-30 cases a month. These young women are described by both men and women interviewees as "unmarriageable" and some support children or elderly parents on their salaries. To make ends meet, they may negotiate to have sex for money with beer-restaurant clients , with whom they may have drunk together a case of beer, and with condom use often forgotten. While the number of brothel workers remained unchanged at about 240 during the past two years according to estimates of one international NGO working in Siem Reap, the number of beer girls has doubled to 400 this year. The two authors, with Cambodian research assistant Vanna Mok, conducted a series of interviews and focus groups during March, 2001 (14). Two focus groups of beer groups (total of 15 ) evaluated the proposed cartoon booklets and videotapes as ways to disseminate information- they did not respond positively to videotape messages, as TV was largely an unknown medium in rural Cambodia, but did ask for copies of the sound-track as an audio-cassette they could play on their Walkmen.
Ian Lubek, Mee Lian Wong, Mondol Moi Clinic HIV/AIDS educator Mr. Sary, Research Assistant Mok Vanna.
Interviewing Mr Sary at Bayon Temple Focus group with Siem Reap beer girls Tee-shirt promoting "Number One" condoms.
The message about 100% condom compliance was also addressed to married women (now 5% sero-positive) and they could use almost identical strategies for persuading their husbands to use a condom. Previous educational campaigns aimed at high schools may be protecting younger Cambodians (Tarr & Aggleton, 1999) , but may not reach the under-age beer-girls from rural settings nor the older orphaned or battered generation of genocide survivors and their wives. Young adolescent and pre-adolescent boys, informally interviewed at the Angkor Wat site, indicated that they knew what [the best-selling condom brand] "Number One" was, and that "you would die from AIDS if you don't use it when you have sex" (Feb. 27, 2001). One young lad of about 12 wore a "Number one" tee-shirt showing a couple negotiating its use prior to having sex.
With the help of local health workers, questionnaires about condom use and cervical gonorrhea testing has commenced at one health centre to gain baseline data. In a series of interviews and meetings with adminstrators such as Dr. Dy Bun Chenn (Director of the Provincial Department of Health), Dr. Kros Sarath from the National AIDS Programme, and front-line doctors, nurses and educators, a community "needs assessment" was carried out concerning the possible creation of an all-in-one "Wellness" clinic to bring together, equip and better co-ordinate all aspects of HIV/AIDS (and STD) prevention, education, acute care, diagnosis, treatment, long-term care and follow-up.
Dr. Uy Borany, Intensive Care Unit, Siem Reap Provincial Hospital Dr. Kros Sarath, Cambodian National AIDS programme and Dr. Dy Bun Chhem, Provincial Director of Health for Siem Reap
This project is being developed in conjunction with the input from the local NGO (The Siem Reap organization for social, health and educational issues) and its medical and community members. In a first stage. the aid of international donors for startup assistance will be sought, followed by sustaining contributions from local community industry leaders (e.g., major hotels, tourism businesses, beer companies, etc.)
Community Reframing of the questions and priorities in action research
The action research programme in Siem Reap in 2001, sponsored by the Elton John AIDS Foundation, was designed to further research the community's reactions to HIV/AIDS and pilot test possible intervention strategies, based upon earlier ideas from the interviews in 2000 . Previous research by Wong and her associates (1998a and b; 1999a and b, see Figures below) had shown how education campaigns concerning 100% condom use could significantly reduce rates of gonorrhea and, consequently, HIV/AIDS infection.
An action research approach, with its more flexible and transparent inter-relationships among theory, research and practice, encourages the de-hierarchization of the role differences between the elite, community-outsider researcher and the local participant, and the suggests the possibility of modifications/changes at each stage of the research in accordance with local community imputs. The original study in 2000 was designed to examine the relationship between traumatization during the Pol Pot period and later risk taking behaviour, including unprotected sex with the "beer girls". (15) While the participants were in fact able to describe the risky behaviour around them, and link it to past events related to their survival, they expressed greater concern about their current health situation and the need to improve it, especially for the women. The international beer companies were taking no responsibility for the after hours activities of their uniformed employees, who flirted with customers in order to sell their quotas of beer for a salary of $2 per day; some would offer sex for money to their clients- usually tourists but also local men-- when both were inebriated. As a result, condom use was often neglected. Married women reported their husbands visiting the beer girls, but not using condoms when they returned home.
As a result, the research programme in 2001 was specifically designed to increase condom use to 100% among both "beer girls" and married women. After the second annual meeting of the local grass-roots NGO group, additional health and social resources are being sought from foundations. Here it was suggested by beer girls and married women that that an additional education campaign be designed to target the local men and the tourists. In addition, it was suggested that the international beer companies be contacted about improving the salaries, health education, and health care opportunities for the young women selling and advertising their products. And as to the question of how to improve the delivery of HIV/AIDS related educational and health services, we organized a community conference on HIV/AIDS in early March, 2001 in Siem Reap to allow all local agencies, government departments, hotel managers (representing the major industry) (16), and NGOs concerned with HIV/AIDS and women's health issues to interact about their programmes. About 20 organizations spoke, and major presentations were made by Dr. Kroh Sarath of the National AIDS Program, as well as both of the authors. Their input, as well as the separate interviews with medical personnel, counsellors and educators, beer girls and citizens in Siem Reap, and later officials and representatives of NGOs in Phnom Penh, also have helped us to better understand the specific sensitivities of local conditions and the need for urgent interventions. (17)
Mme Mu Sochua, Minister of Women's and Veteran's Affairs. The Elton John AIDS Resource Centre Sihanouk City of Hope, Phnom Penh.
In this project, as we receive more feedback and ideas of local citizens and professionals concerned with HIV/AIDS in Siem Reap, we are constantly adjusting the project, from initial observational tourism and fact-finding, through systematic data gathering on past traumatization and current risk-taking, discussions and feedback to the community of these preliminary findings, to a re-orienting of the project towards more urgent intervention involving cultural translations and reworkings of educational interventions with specific target groups identified by the local community, and attempts to improve medical treatment and education through a co-ordinated Wellness Centre. This has meant re-evaluating the relationship between our guiding theories, the research outcomes of our fact-finding interviews and experimental interventions, and our actions aimed at attitudinal, behavioural and social change in Siem Reap. More generally, such a programme of action research may be used as a model for other communities in Cambodia, and elsewhere , which may be similarly facing the HIV/AIDS pandemic.
Apfelbaum, E. (2000a. "And now what, after such tribulations?" Memory and dislocation in the era of uprooting. American Psychologist, 55, (9), 1008-1013.
Apfelbaum E. (2000b). Remembering and memorializing in the face of uprooting. Revisiting Maurice Halbwachs. Paper presented to the 19th Annual Meeting of the European Society for the History of the Human Sciences. Berlin, 25-29 August.
Argyris, C. (1975). Dangers in applying results from experimental social psychology. American Psychologist, 30, 469-485
Chataway, C. (1997). An examination of the constraints on mutual inquiry in a Participatory Action Research project. Journal of Social Issues, 53, (4), 747-765.
Cherry , F. (1995). The "stubborn particulars" of social psychology. Essays on the research process. London: Routledge.
Cherry, F. & Borshuk, C. (1998). Social action research and the Commission on Community Interrelations. Journal of Social Issues , 54, (1), 119-142.
Human Rights and Equal Opportunity Commission of Australia ( 1997). Bringing them back. Report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from their Families. Sydney: Sterling Press.
Kiernan, B. (1999) The Pol Pot Regime: Race, power, and genocide in Cambodia under the Khmer Rouge, 1975-79 .New Haven, CT.: Yale University Press.
Kral, M. J. & Minore, J. B. (1999) Arctic Narratives: Participatory Action Research on Suicide and Wellness Among the Inuit. Paper presented at the Biennial Conference of the Society for Community Research and Action, Yale University, June 1999.
Kren, G. M. & Rappoport, L. (1994). The holocaust and the crisis of human behavior. (2nd ed.) New York: Holmes and Meier.
Lewin, K. (1946). Action research and minority problems. Journal of Social Issues, 2(4), 34-46. ).
Lewin, K. (1947). Frontiers in group Dynamics: II. Channels of Group Life; Social Planning and action research. Human Relations, 1, (2), 143-153.
Lubek, I. (1997). Reflexively recycling social psychology. A critical autobiographical account of an evolving critical, social psychological analysis of social psychology. In. T. Ibañez and L. Iñiguez (Eds.).Critical social psychology. (pp. 195-228). London: Sage.
Lubek, I. (2000).Understanding and using the history of Social Psychology. Journal of the History of the Behavioral Sciences, 36, (4), 319-328.
Lubek, I. & Stam, H. (1995). Ludicro-experimentation in social psychology: Sober scientific versus playful prescriptions. In I. Lubek, R. van Hezewijk, G. Pheterson & C. W. Tolman (Eds.) Trends and Issues in Theoretical Psychology. (pp. 171-180). New York: Springer.
Peters, M., & Robinson, V. (1984). The origins and status of action research. Journal of Applied Behavioral Science, 20 (2), 113-124.
Pran, D. (1999). Children of Cambodia's Killing Fields. Memoirs by survivors. New Haven, CT: Yale University Press.
Ratliff, S.K. (1997) Caring for Cambodian Americans: A multidisciplinary resource for the helping professions. New York: Garland Publishing.
Sanford, N. (1970). Whatever happened to action research?. Journal of Social Issues, 26(4), 3-23.
Selby, J. (1999). Cross-cultural research in Health psychology: Illustrations from Australia. In M. Murray & K. Chamberlain (Eds.). Qualitative health psychology: Theories and methods. (Pp. 164-180) London: Sage.
Stam, H. J., Lubek, I., & Radtke, L. (1998). Repopulating social psychology texts: Disembodied "subjects" and embodied subjectivity. In B. Bayer & J. Shotter (Eds.). Reconstructing the psychological subject.:Bodies, practices and technologies (pp. 153-186).London: Sage.
Stam, H. J. , Radtke , H. L., & Lubek, I. (2000). Strains in experimental social psychology: A textual analysis of the development of experimentation in social psychology. Journal of the History of the Behavioral Sciences, 36 (4), 365-382
Tarr, C. M. & Aggleton, P. (1999). Young people and HIV in Cambodia: meanings, contexts and sexual cultures. AIDS Care: Psychological and socio-medical aspects of AIDS/HIV, 11, (3), 375-384.
Wong ML. (1990). Participatory research and community health development in Sarawak. Arbovirus Research in Australia: Proceedings of the Fifth Symposium.(pp. 244-247)
Wong ML. (1991). The Berawans in Sarawak, Malaysia. In Osteria T (ed) Women in Community Development. Singapore: Institute of Southeast Asian Studies, 1991: 10-31
Wong ML, Chan R, Koh D, Wong CM. (1998a). Theory and action for effective condom promotion. Illustrations from a behaviour intervention project for sex workers in Singapore. In Burchanan D and Cernada G (eds) Progress in Preventing AIDS? Dogma, Dissent and Innovation: Global Perspectives. New York: Baywood Pub. Co.,1998: 243-2
M. L. Wong, K. W. Roy Chan and D. Koh (1998b). A sustainable behavioral intervention to increase condom use and reduce gonorrhea among sex workers in Singapore: 2-year follow-up. Preventative Medicine,27, 891-900,
Wong, M.L., Chan, R.K.W., Chua, W.L., Wee S. (1999a). Sexually transmitted diseases and condom use among free-lance and brothel-based sex workers in Singapore. Sexually Transmitted Diseases 26: 593-600.
Wong, M.L., Chan, R.K.W., Koh, D., & Wee S. (1999b). Increase in oral sex and pharyngeal gonorrhea: an unintended effect of a successful condom promotion programme for vaginal sex. AIDS, 13 (14), 1981-1982.
1. Paper presented at the annual meetings of the European Society for the History of the Human Sciences, Amsterdam, Aug. 14-18, 2001. This research has been supported by a research grant (2000-2001) and a travel conference grant from the RAB/SSHRC , University of Guelph, and during 2001-2, by a grant from the Elton John AIDS Foundation of London. Written in part while IL was visiting at the Australian National Centre for HIV/AIDS Social Research, University of New South Wales.
2. Brydon-Miller (1997) traces the history of Participatory Action Research (PAR) only back as far as the 1970s, and sees a variety of influences, including educational activist Paolo Freiere, Marxism, feminism, and the critical theory of Habermas. While she talks of varieties of "participatory research", no mention is made of Lewin's earlier "action research" formulation. Fine et al (in press) provide a more detailed look at earlier Lewinian social psychological precursors as well as more recent feminists and social activists. They note that Paulo Freire and Ignacio Martin-Baro had both, "more recently, structured a set of commitments to ...[PAR] that move Lewin well beyond the borders of psychology, into an explicit analysis of the relation of science to social inequality, community life and radical social change" (p. 3). And they suggest that "a dynamic or dialectical confrontation between common sense and systematic observations, followed by intensive reflection and action, engaged at the provocative borders between insiders and outsiders, were the recursive steps of [PAR]. " (p. 3)
3. Lewin (1946) uses both military and industrial examples in describing what he first calls "rational social management" which "proceeds in a spiral of steps each of which is composed of a circle of planning, action, and fact-finding about the result of the action. (p. 38).
4. Chataway's (1997) work on conflict resolution among the Kahnawake First Nations people offers an excellent model. Sharon Ratliff similarly (1997) examined multi-disciplinary sensitivities in " caring for Cambodian Americans"; see also Kral & Minore's (1999) collaborative work on suicide prevention in Inuit communities in the Canadian Arctic, and Jane Selby's (1999) work on Palm Island with risk issues concerning Australian Aboriginal's health and safety.
5. Various studies have previously combined socio- historical and psychological perspectives on devastating political events such as genocide, mass rape, and uprootings, (Kren & Rappoport, 1994; Apfelbaum, 2000; Human Rights and Equal Opportunity Commission of Australia, 1997). Events of the Cambodian genocide during the Pol Pot regime (1975-1979) have already been described by historians and political scientists, as documented by Ben Kiernan (1999), head of the Yale University Cambodian Genocide Programme, and through personal narratives gathered by Dith Pran, (1997), whose own survival was depicted in the movie "The Killing Fields"- in France, this film was title "La Dechirure" referring to the tearing apart of Cambodian societal structure.
6. Political instability and fighting continued to tear apart the country, first with a decade long occupation by the Vietnamese. In the 1990s, the UN forces arrived to separate the warring factions and permit elections of a new government in 1993. These events impacted upon Cambodians socially and psychologically- both those who survived within Cambodia and those who lived in exile. Among the aftereffects studied have been substance abuse, risk taking, and suicide (Pran, 1997; Ratliff, 1997), which have also been seen in other populations of uprooted survivors of genocide.
7. Such sexual tourism largely was shut down in much of Thailand in the 1990s, in part due to pressures from the Women's movement and the medical community in dealing with the HIV/AIDS epidemic -some former sex-workers were offered safer and better income producing opportunities , as regulated Thai massage specialists, working in the major hotels. However, one side-effect of the decrease in commercial sex activities in Thailand was that the sexual tourism trade has now simply moved one country eastward into Cambodia.
8. The UN soldiers, it was reported, sometimes earning up to $100 per day, came from a variety of countries, including nations already having high rates of HIV infection within their armed forces. When the UN soldiers left, the United Nations and various Foundations and agencies helped in the mid-1990s to restore the Angkor Wat temples and de-mine the area, Local owners of the hotels and recreational nightspots for the well-paying soldiers continued to recruit rural women into the sex trade, but now for the deminers, and by 1996, for the tourists, who began coming in increasing numbers to Siem Reap.
9. In Siem Reap, a small group of educated survivors work as guides, as translators, and with NGOs. As children, they lost their families and became uprooted. And in a fashion which resonates with other uprooting experiences among Shoah survivors, South American exiles, Australian Aboriginals of the "Stolen Generation" (Apfelbaum, 2000), and Inuit and First Nations children uprooted from their communities (Kral & Minore,1999) , some now engage in high-risk behaviours that can threaten self-destruction--- in this case, high rates of alcoholism, minefield and road accident deaths, and unprotected relations with sex workers. Similar patterns (for example of substance abuse) have also been found in the Cambodian exile communities in the U.S. (Pran, 1997).
10. This intervention project relied, initially, on theories, methods and approaches first suggested by the fields of history and social psychology and their inter-linkages, especially concerning how memories of uprooting and traumatization (during the Pol Pot genocide period was linked to later risky adult behaviour (drunk-driving, unprotected sex, etc.). Some of the theoretical ideas driving this initial study were outlined by Erika Apfelbaum in a keynote address to ESHHS last year in Berlin (Apfelbaum, 2000a, b). But once in the field, as Lewin and his students discovered half a century earlier, the research and related interventions have taken on broader (inter-disciplinary) dimensions according to the realpolitik of community needs, and the initial project was then temporarily shelved when participants gave highest priorities in the interviews to the growing community fear of the HIV/AIDS pandemic and the need to quickly address it.
11. . In 2000, they generally agreed on insufficient medical facilities, the lack of treatments for even opportunistic infections and believed medications, anti-biotic or anti-viral, were not affordable. Extended HIV/AIDS education and sex-worker outreach programs were also stressed, along with preparation of orphanages for "HIV/AIDS babies".
12. A second serendipitous event brought the two co-authors together: On Lubek's way back to Cambodia to conduct interviews in 2000 , he stopped for a few days in Singapore to work with John Greenwood (2000) on the latter's paper on the history of social psychology, and was introduced to several colleagues there working on health issues, including Mee Lian Wong, whose work in public health has been adapted for use in Cambodia .
13. The original graphics were redrawn for Khmer readers by Bab-Rethba in Paris, while in Singapore translations, lettering. cassette recording and technical assistance were offered by Khieng Sochivy, Chheng Sim, Seng Sophea, Lee Teck Ngee, and Chew Keng Lee, with additional lettering in SIem Reap by Mok Vanna.
14. At the University of Guelph, transcriptions and content analyses are currently underway by a team of undergraduate students including: Dallas Giroux, Stephanie Collins, Meghan McCourt, Sandra Dixon, Tara Hannah, Heidi Lund, Kathryn McDonough, Jennifer Hiemenga, Liz Branco, and Cyril Arfeuille.
15. Among men who had not yet formed their own family units, some reported high risk behaviours, including abuse of alcohol with related road accidents, and unprotected sex with various sex-trade workers, who first arrived in Siem Reap with the UN forces in the early 1990s- brothel prostitutes, discotheque dancers, Karioke singers, and young (often under-age) "beer-serving girls". Some married men also reported visiting the beer girls when drunk, and getting caught up on their lost adolescence.
16. The managers of three hotels, Salina, Grand Angkor, and Sofitel materially supported this activity.
17. In Phnom Penh, we met with Mme Mu Sochua, Minster of Women's and Veterans' Affairs, a Secretary of State for Health, contacted National Centre for HIV/ AIDS (NCHADS) , NGOs such as Médecins sans Frontières, AFESIP (which rescues enslaved sex workers), Cambodian Information Project; Sihanouk, Calmette and Sihanouk Centre of Hope Hospitals; and Elton John AIDS Resource Centre, In Siem Reap, Drs. Dy Bun Chenn and Kroh Sarath oriented us, and extensive information given by representatives of Angkor Children's , and Kanta Bhopa III private hospitals; NGOs such as CARERE, Caritas, CARE, Concern, the Rose Centre; doctors and nurses from Mondol Moi Clinic(Dr. Em, Mr Sary and Ms. Maryan Chhit), from the Provincial Hospital (Dr. Uy Borany, Dr. Mol Neng and colleagues), Mme Ou Bory of the Children's Orphanage, and hotel managers Gilbert Madhavan and Mr. Noi.