Dr Jennifer Watermeyer, Health Communication Research Unit, University of the Witwatersrand

“communities and patients seem far more open to arts as a tool for allowing their voice to be heard, allowing them to become empowered”

Interview with Dr Jennifer Watermeyer, member of the Health Communication Research Unit and a Senior Lecturer in Speech Pathology & Audiology, University of the Witwatersrand (6th August 2014).

VH       Maybe if you start by telling me a bit about your organisation or the work that you do within your organisation…

JW       OK. So the Health Communication Research Unit started off in about 2004; I was an undergrad student, and Claire [Penn – Director of the Unit] had started her focus on qualitative research in healthcare contexts. I think that really came out of a frustration that she had with her own discipline, of Speech Pathology, and just wanting to – extend beyond the boundaries of that discipline, and really use what we know about communication, and particularly about interpreting, to get into healthcare contexts and make a difference.

So she started with a couple of projects looking at interpreting – and looking at it from a linguistic angle, and then the project really – grew into something more, and then we started [thinking about] ‘OK well, we’ve had a look at doctor-patient interactions, what else can we look at? So, I came on board as a postgrad, and looked at pharmacy interactions; other people started looking at other interactions; and we found that we built up this collection of … different healthcare fields. And then once we’d looked at a number of professions and healthcare interactions, we started to branch out a bit further, and say ‘well how can we turn this into training, or – something meaningful, that would actually impact on practice in clinics?’

And that has really been our primary focus in the last few years. And out of that has grown [work with] for example, Drama for Life – working in an interdisciplinary way with specific clinics, with specific people from other university departments … With a focus on disease-specific, site-specific training, research, recommendations to sites.

Essentially what we are doing is trying to empower health professionals and teams in particular – rather than saying ‘OK we’re going in to fix these nasty doctors’ [laughs] or ‘deal with these lazy nurses’ (because I think that is often the perception out there); so we’ve looked at the team, and done training with teams.

Out of that basis grew this focus on – almost an action research approach to what we do. And – from that has grown funding support, so we have a lot of funding from various organisations, we’ve grown our postgraduate numbers, we’ve grown our outputs. And one of our goals has really been … not only to support and empower clinics locally and health professionals throughout Africa, but to actually focus on establishing a research area in South Africa, because ‘health communication’ didn’t really exist. There were a couple of splinter people doing research here and there but nothing really focused.

So, a lot of the work of the unit has been around trying to establish that niche. And also a commitment to quality research, and trying to publish internationally. And trying to showcase our work at international conferences, in international publications etc.

VH       You were saying something quite interesting about conferences before …

We were talking about … perhaps a lack of communication between South African and scholarship from parts of Europe, or the rest of the world.

JW       Yeah, I mean we’ve gone to a number of international conferences over the past decade. And it’s been a hard journey. We often find that we are the only ones from outside of Europe and the US and Australia. Those seem to be the strong regions in terms of health communication research. And we’re usually the only South Africans; the only Africans, often. … I think our issues are very different, but in a way we have such strengths – in our diversity, and in our approach. And South Africans are known for making a plan, and making things work when we don’t have resources. And being cut off from the world during sanctions and apartheid really taught us that. But it’s meant that now, as we enter into an international arena, people still look askance and they say ‘oh, it’s the South Africans … oh shame, they’re trying hard…’ And that is really the attitude that we’ve found in a lot of contexts.

And especially if you mention the word HIV there’s an attitude of … ‘it’s got nothing to do with me. It’s not a European problem.’ So we’ve learnt to hide the South African bit, we’ve learnt to hide the HIV bit; and although we present on those topics, we don’t flash it around in the title, in the abstract, to the same extent as we used to; because we found that when we did, the response was often not wildly enthusiastic.

VH       Would you say it’s a failure of imagination, something to do with not being able to apply the concept of AIDS as a chronic disease to – what might be thought of as a ‘European’ chronic disease?

JW       Yeah, I think it’s partly that. I think it’s also a lack of understanding of the South African context. I think people really don’t know enough about us. And it’s only after many, many years of really trying hard, and going to the same conferences, and building up research links and collaborations, that people have started to see that our research has value. And that the research that we’re doing is in some ways much more advanced and further down the line than what some of our colleagues in other countries are doing.

… It’s hard to get that recognition. … We’ve had [similar experiences] with publications – and I know it’s not just us, it’s [also] other researchers around South Africa who’ve had the experience of being told by journal editors that we need to get our language edited. I think any time the word ‘Africa’ pops up, there’s an assumption that it’s not good enough, it’s not – of interest.

VH       That’s shocking.

JW       It is shocking [laughs], but it’s kind of – it is part of our role, too, to go out there and educate people, and that’s why we trek across the world to these conferences, that’s why we pay huge sums of money and stay in dodgy youth hostels etc. In order to showcase our work.

VH       There’s a kind of interesting comparison with the arts and health world in a way … I think people in that world have also invested quite a large proportion of scant resources on pitching up at conferences where they wouldn’t be expected. And trying to demonstrate that it is possible to have a sophisticated concept of health that doesn’t come from a clinical, pharmacological model. I mean it’s a different issue; but it’s all to do with prejudices about what constitutes valid intellectual thought, valid academic work, valid – stuff that could potentially feed into policy.

JW       Yeah, and I think ultimately what it really says is that medicine is still so dominated by – a medical point of view, by a quantitative background, by clinical trials, and that mindset is really what we’re [up] against.

I was talking earlier about instances of supervising students where you put together a beautiful qualitative project and then you have to defend, and fight, and go through a whole process of trying to get it through some committee who’ve decided that they don’t think qualitative research is something that medics should be doing. So that has been difficult. I’m dealing with an issue at the moment with a student who’s put together a lovely project that’s qualitative and quantitative, and no, they don’t want the qualitative bit, they’re prepared to approve the quantitative bit but not the qualitative. And my argument was it’s actually not a project without both elements. We’ve had to prove … that I’m somebody who has qualitative experience, I’m coming on board with this project, I’ve worked on projects before at the clinic. And even with that kind of argument, they’re still saying No. Not interested. So that’s the mindset.

VH       And it’s unfortunate because there obviously are individual doctors who feel very differently about that – individual researchers who feel very differently about that.

JW       Yes, and I’ve come across some wonderful people out there. I’ve done research for example with [people like] Ashraf Coovadia, who’s at Rahima Moosa Mother and Child Hospital; who heard me speak at a conference and came up to me and said ‘I love the work that you’re doing and I want you to do research at [my] clinic, and I’m completely invested in learning about qualitative research, having qualitative studies done at the clinic…’ And that process that has opened doors for other students to start qualitative projects, for other staff members at that clinic to learn about qualitative research. But that’s – that’s the exception, not the rule.

VH       How much of the HC unit is focussed on health outcomes … Is it more about – behavioural change, or do you have a sense that you’re having a direct impact on the health of communities or individuals?

JW       That’s a very tricky topic to answer and it’s something that we’ve grappled with tremendously over the years … essentially what we are working with is the premise that if we improve communication between health professionals and patients – if we improve understanding, if we improve relationship, rapport, trust, all of those elements, then we are hopefully promoting … improved adherence to treatment; because if you have buy-in, and you have a relationship or a sense of trust between a patient and a health professional, that patient is more likely to adhere to that treatment. But then how do you measure that? And that’s the issue that we’ve grappled with. How do you measure for example going in and doing a training workshop on communication skills? How do you measure whether that has impacted positively, caused change etc.?

So, we’ve had a number of big projects over the years where we’ve tried, sometimes quite ambitiously, to look at the micro aspects of interactions and communication. And do a sort of a pre-/post-intervention assessment. With mixed results. Because communication is so complex, it’s not something that you can very easily measure. And so what we’ve been doing over the last few years is working on the basis that this is our premise: we are anticipating that it will lead to improved adherence, improved health outcomes, improved patient follow-up, patients actually arriving for consultations etc. But we can’t measure it [very easily].. And there are studies out there, for example in the States – people have done work looking at things like the link between communication and adherence. And so we’re building our research on what other people have done.

VH       Again there’s quite a lot of parallels with arts in health – I think it’s that thing of quite a complex intervention that’s working on a number of levels, and how do you disentangle one aspect of it from another aspect of it…

JW       [with the arts] … I think there are huge opportunities for getting involved with communities. And what we’ve found through some of our work is that communities respond very positively when you bring the arts in. So for example drama; or other people have done projects like memory boxes, which involve drawings, and narrative. And allowing people to feel that their voice is being heard. And I think the arts are brilliant tools for enabling that to happen.

VH       So it’s primarily to do – for you – with finding ways of hearing the patient’s perspective, voice, narrative, all those things…

JW       Yeah. And to be honest I think in terms of getting an in, and getting the buy-in, communities and patients seem far more open to arts as a tool for allowing their voice to be heard, allowing them to become empowered etc. … And that’s been a very positive way of getting involved.

VH       Why do you think that is?

JW       I think its because the medical fraternity are so entrenched in their ways, in what they’ve been taught, in how they’ve been taught – and it’s only through experience that I think some of them have their eyes opened to the fact that the arts have a place. But I think communities come without those preconceived ideas. And I think [that in] a lot of our communities in South Africa, diversity brings with it an attunement to things like arts, music. Storytelling is something that is very much entrenched in some of our African cultures, for example. So they’re far more open to that.

VH       So it’s a way of tapping into something which is already an accepted form of communication rather than imposing something which isn’t?

JW       Absolutely, yeah.

VH       And [do] you have an example of a project where you think that’s worked particularly well, and where there’s been a specific intervention that you think has done something that couldn’t have been achieved [otherwise]?

JW       I think the project that I would think about most is the one that we did in a clinic in Mpumalanga, where we spent quite a long time doing preliminary interviews with patients, community members, staff, about some of the challenges at the clinic, what was working well – and based on that research we went and designed an intervention programme that involved drama techniques … things like role-playing difficult situations, communicating with children for example. And our aim with that was really to empower the staff and develop a sense of teamwork.

And that was a very successful workshop … over two days; and out of that came a follow-up study where we went back six months later and said ‘OK, how did that workshop impact on you, and your practice?’

And what we saw was that staff were then able to take those techniques and implement them in the way that they practised. So, for example, some of the staff had developed songs – there was a song about handwashing, there was a song about TB – and then taken them into communities. … one of the staff members [also] had an adolescent group where she started working on developing a film about the community, about the challenges that they faced.

So that workshop and the introduction of drama techniques … actually empowered the staff to use those same tools, or similar tools, to reach out to communities. Which was great.

VH       I think it’s quite easy for artists to be – protective of their methodology … I feel very strongly there’s a case for the professional artist in a lot of these situations, but it’s interesting … in a way one of the greatest values is handing over those tools; so they’re not – really yours to keep in the end …

JW       Yeah, ultimately surely that should be the point – that we empower other people to run with it, and to take the tools that we teach them; and take those into communities to effect change? Because we can’t possibly be doing all of this prevention and promotion and educating and empowering; so I think that’s a big component of an action research approach – to actually train people to then carry it out themselves.

VH       Do you have any sense of the relationship between that kind of art intervention and the mainstream art world? … Does it feel like a continuum or does it feel like they’re completely distinct practices?

JW       For me I think it feels like it’s quite distinct. And certainly in the academic environment, and from my experience of having worked with the drama department for example, it seems to be quite disconnected. So we have programmes where people, for example, go in and do education on a health topic in schools and prisons, in clinics. But that is very different in some ways to what they would be doing on a stage, as a theatre production. Although I think their aim is to try and bring the two together, and to train students and enable students to be able to do both, I think there is quite a disjuncture between mainstream arts and what we’re doing in healthcare practices.

And perhaps that’s just because it’s a fledgling field, in terms of what we’re doing in those healthcare contexts; … Catherine Burns [in her interview here] spoke about trying to establish a medical humanities focus in South Africa, and because we’ve never had that, I don’t think there’s ever really been much of an interface between mainstream arts and healthcare contexts [in South Africa]. And so by actually establishing fields like medical humanities and health communication in this country, that gives us opportunities to – to go forward. And start to interface with – the arts.

VH       How do you feel you sit in terms of mainstream health practice at the moment?

JW       … It does feel a bit like a starfish approach sometimes: that through your research, you have the opportunity to educate a couple of people, and to open a couple of people’s eyes to this world of looking at healthcare in a different way. It’s not something that you can reach out to the masses with – at this point. [laughs] The medical masses are not necessarily receptive; so it’s very much … changing one health professional’s perceptions, or one clinic’s perceptions, at a time.

VH       [Do you have a] sense of whether there is such a thing as ‘arts in health’ in South Africa? I’m aware that it’s not really used as a term, but – but do you think it’s a practice that exists and is established … in terms of what’s happening ‘on the ground’? Are you aware of stuff when you go to clinics?

JW       On the ground, I would say for the most part no. But you do find … people like us, people like DfL [Drama for Life], for example, who are actively going into healthcare settings and doing small projects based on the arts, or bringing in qualitative research. And I think the arts and the qualitative side of things very much go hand in hand – the humanities, the arts, qualitative [research]. But for the most part, no – I don’t think there’s a field or a – an established – ‘anything’.

VH       But it creeps into conferences in strange ways; you were talking about Section 27 and the work that they do –

JW       Yeah – there’s a very strong activism base here in South Africa; so the Treatment Action Campaign, Section 27, and other organisations, are very, very vocal, and it’s really because of their hard work that we have, for example, such a big ARV rollout programme. So activism has always been something that’s very strong in this country. But how that interfaces with the arts would be an interesting thing to look at – and I mean certainly my experience recently at this TB conference in Durban was that [laughs] the interface between the activists and the medics was not a particularly easy one. … a lot of the medics were not particularly happy to have the activists there. … So [laughs] – there’s work to be done, I think.

VH       It struck me that [in the context of health activism] perhaps that the arts are just one of a range of tools, rather as they are for you, that can be used to – to push an idea or to change a way of thinking, something like that?

JW       … I was interested along those lines to see that at this TB conference there was a lot of focus on films, for example, and – and actually showcasing films that tell narratives of people who have experienced diseases.

My sense is that we have a very big job, and a – responsibility – as artists, as humanitarians, or as qualitative researchers – to focus on quality in the way that we introduce the arts into medicine. So if we have quality productions, where there has been research underpinning it … really fantastic production … not just a group of [laughs] fluffies coming together and putting something on … that is when I think the medics really listen, and are interested.

So that would be my point of view: that I think we need to have a commitment to quality; because we are – we are very much still seen as the fluffies [laughs]; and unless we actually work on changing that … there will always be resistance to getting the arts into healthcare, and medicine.

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Emma Durden – Theatre & Health Consultant

“something like 82% of the audience went for HIV testing – within a week of having watched the theatre piece”

Interview with Emma Durden – Theatre & Health Consultant (11/8/2014)

VH       Could you describe your work briefly…?

ED       I suppose my work is predominantly summed up as ‘theatre for development;’ or it’s a bit broader – I would say ‘communication for development.’

So although most of it is theatre-based work that looks at developing communities – either through addressing health issues or through addressing other issues – other work is far more focussed on health communication, and understanding what problems there are in particular areas that prevent people from taking up messages, and therefore taking up health services.

VH       And you come from a theatre background, your training is in theatre?

ED       Yeah. My training is particularly in educational theatre. So although I do quite a lot of writing and directing of applied theatre work, my focus of study was very much on using theatre to educate, as opposed to learning how to act, and direct, and so on…

VH       And how much of your work now would you say intersects with health and healthcare, or wellbeing?

ED       I would say all of it is related to wellbeing of some sort. So if it’s not particularly health then it’s looking at gender-based violence, or xenophobia, or other social issues. So when I work for example with community-based theatre groups with Twist Projects, the main focus of my work is to help develop those groups to a point where they are sustainable as organisations on their own; but the work that they do is all very much focused on social issues.

VH       Would you say that that’s a broad trend in South Africa, within community theatre?

ED       For anybody who wants to sustain themselves with funding, they know that applied theatre is where the funding is; it’s not in creating theatre, but in using theatre as a vehicle to get to some other objective. So – we’re kind of actively encouraging it amongst theatre groups, [by] saying ‘if you want to survive, this is one of the things that you need to look at.’

VH       D’you think that, funding aside, there’s a desire within those community groups to address social issues anyway?

ED       Yeah, definitely. I did some research in 2012 … I interviewed 15 community theatre groups, and they all felt very strongly that they had a responsibility as artists … to talk about the things that others don’t talk about, in their communities.

So they are doing that work regardless. But they’re not making the connection between the health industry, or the health field, and the particular issue that they’re working with. And a lot of the time it’s quite sensationalist. So there was a project that was artistically really interesting – it was a piece called ‘The Seed’ by a theatre group from Umlazi township, south of Durban … It was on HIV, and the idea was that HIV was the seed and it grew into AIDS; it was kind of allegorical in that way. But it was very sensationalist; the guy who got HIV and passed it on was a worker, who went to town to work, and he got it from sleeping with a prostitute…

So the problem with community projects looking at those issues is that they’re really looking at stereotyped ways of, say, infection, in this example. And it doesn’t leave space for people to talk about the fact that it’s far more mundane than that, and far more ordinary, and it affects everyone. As soon as they sensationalise it, people start to stereotype types of people who get HIV, rather than types of practices.

I watch that kind of theatre coming out of communities, and I feel anxious for the messages that it contains, or that it’s passing along. So … I think there’s space for intervention, from – people like me, who are … thinking more about the consequences of sensationalising it into theatre, rather than seeing theatre as a way to interrogate those issues.

VH       There’s quite an interesting parallel with a woman I met at a conference in Australia [whose] … organisation worked with the media to try and de-sensationalise representations of mental health in television [drama] and advertising … And it’s – it was exactly the same issue. Well, in a way it wasn’t quite the same issue, because I think there it was about tackling something that was being used as a dramatic device –

ED       Yeah, it makes for a good story to have a madman in it.

VH       Whereas it’s interesting that you’ve got – the slight contradiction of wanting to be honest about what’s happening in your community, but at the same time turning it into something that scapegoats certain members of that community, potentially, or –

ED       … I think there’s a huge scope for research in that area as well. What theatre should do is allow for exploration of all of the grey areas; but what people tend to do in theatre is make it black-and-white. So that it contrasts, and it has dramatic … viability. But then the audience has no space to negotiate what it means, because they’re being told that this is what it is.

… Apart from in the design of the theatre, what a lot of the community theatre groups don’t do is facilitate discussion after theatre; so people will come and watch and go. And they know that [it has a] kind of agenda-setting function, and people will go home and talk about the play, but there’s no mediated discussion about the play, which I think is more useful.

VH       So there’s no counterbalancing information being given?

ED       Yeah.

VH       And in your work; how much would you say is to do with, if you like, measureable health outcomes? Do you think you are – do you feel aware that you’re having an impact on individuals’ and communities’ health? I’m thinking now more specifically about the kind of work that you do with AIDS –

ED       We did a project years ago in a factory – I do a lot of theatre in factories – and this particular project was the first time we actually were able to measure it. And something like 82% of the audience went for testing – HIV testing – within a week of having watched the theatre piece.

But there’s no control group to compare that to. So everyone in the plant – there were 1,200 people – everybody there at the factory saw the play, and 82% of them went and got tested in the upcoming five days.

And that’s a real measureable; but most of the time we don’t have the chance to do that, so everything’s anecdotal afterwards … Particularly with the stuff we do in factories, clients come back to us and say ‘people are still talking about it,’ or ‘… they’re still singing that song at the end of the play,’ or ‘they still refer to that character who did this or that,’ but we haven’t really been able to measure whether there’s an uptake of messages – or a reduction in injuries, or whatever the key objective is.

We could find that out, especially with the injuries – because we do a lot of the work in factories with health and safety officers, so they’ll come to us and say ‘we’ve had seven hand injuries in the last month, can you do a play on hand injuries;’ and we could go back to them and say ‘well, what are your injury rates for the next six months?’ But we don’t usually do that.

VH       I suppose in a way the proof – in terms of that kind of industrial work – is in the continued employment of theatre practitioners in the field.

ED       Yeah … with that theatre project that we do in factories, we have about four clients who have used us consistently for ten years. And almost every year they come back, sometimes a couple of times a year … So they obviously are convinced that it works. And I’m convinced that it works [laughs].

VH       What about things like wellbeing, because this is becoming quite a big deal in the UK at the moment – I suppose an idea of moving away from health and illness and thinking more about people’s quality of life? Do you think that the work that you do has an impact on quality of life, wellbeing, resilience, capacity to cope with illness, that kind of thing?

ED       Definitely the industrial theatre stuff that we do does have an impact, because we focus a lot on what they call ‘employee assistance programmes,’ so we encourage people to get counselling if they’re stressed, or we provide a list of potential coping mechanisms; … so we’ve done quite a lot of work focusing on stress. [And] other work on kind of slowing down, checking your numbers: your blood pressure, and cholesterol, and your BMI, and those sorts of things – which I think fall into that wellness category, specifically health-related wellness. But beyond that – beyond industrial work – I don’t think much of the work that I do focuses on that.

Although having said that, last year I worked on a campaign particularly for women, and a big focus of the campaign was on self-esteem, and knowing yourself, understanding your boundaries, understanding how to communicate in relationships; and I think … that had a real impact on women that we did workshops with, and they loved that campaign, because it was very much about being a woman, and understanding yourself, before starting to look at health-related issues. So it was essentially a sexual and reproductive health campaign, but the getting-in was ‘who are you, and how do you define yourself?’ And people don’t get the chance to explore that very often, and I think that they really appreciated the space to do that in the workshop that we did. So that Zazi Campaign runs in partnership with the Department of Health and JHHESA [Johns Hopkins Health and Education South Africa]. Zazi, which means ‘know yourself,’ or ‘to know.’

VH       And what about research? Your academic links are pretty strong, but what relationship would you say that your work has with research, and how do you present your work in a research context?

ED       Some of it is based particularly on recent research in the area. So … because I supervise students, and I have links with the university, I do read recent stuff and I think this gets assimilated into what I’m writing for theatre or what I’m talking about when I’m working with theatre groups, although it’s not particularly researched in that context, but is more general … That kind of baseline research, or prior research – we don’t do that directly, we just pick up on what’s been done around the area (the area not geographically, but the field of discussion). And then research into impact or whatever – we’ve done very little of that.

VH       But you do use theatre as a research tool – which is interesting.

ED       Yes, in an un-formalised way. So when you do what they call ‘process theatre,’ which takes people through a process of creating a play, then that would be seen as theatre for research – or theatre as research, because then, in the process of creating the play, you are seeing how people respond to or frame a particular problem. And I don’t do very much of that process theatre, or that participatory creation of theatre. I have done in the past, so my PhD is a lot more on that, but recently I haven’t done much of that work.

VH       And … the MAs [you supervise], for example, they’re theatre students … ?

ED       They are in the Centre for Communication in Media and Society [at the University of KwaZulu Natal], so they’re more about communication and development studies, and less about theatre. But … their undergrad degrees or their honours degrees would be in theatre; and the work that they do most days is theatre: participatory theatre, and role-play-related work.

VH       And they use those techniques to gather information about a particular topic, which is often health-related or social development-related?

ED       Yeah. So they’ll do role plays on – negotiating condom use; and the result of that role play would inform how they know young men are thinking about condom use. But it’s not really well documented, so that work is often done far more as an intervention than as research. So there’s a lot of space for research in those areas, I think, too.

VH       I find it interesting that you’ve got theatre undergrads going into social research … and using their theatre techniques. So rather than a social scientist bringing in a theatre practitioner, you’ve got theatre practitioners working as social scientists.

ED       Yeah. I think that’s definitely the trend, far more – that it’s the people with the skills who are applying them in a particular context, rather than the people from the context coming out and trying to find the skills.

VH       … I’m not sure but I would say it tends to be the other way around in the UK. Or at least that the concept of using a theatre practitioner or an artist as a social scientist is not particularly popular, or well-developed. There’s much more of a sense of people working in silos in that way.

ED       Quite often we have to fight for recognition in the field. So I know it happens quite a lot with the medical field – that they don’t see this kind of social science as valid enough research to make any impact on what they’re saying about HIV, or whatever the issue is. Yeah, so I suppose there have been times when it’s been more difficult to negotiate that; but I think now everyone’s kind of fairly clear that this is how it works; these are the people who have the expertise in this area. I think also a lot of the work is very much about the interventions and who can access those communities; and theatre groups or theatre practitioners can access those communities far more easily than just pure researchers can.

VH       That’s interesting – because they already have a relationship there? Or because theatre is a more accepted –

ED       Yeah, a more popular tool, or a popular pastime.

VH       Related to that – do you feel like some of the work you do is having an impact on policy in any way? Either locally or nationally, d’you think it’s getting to the right people?

ED       I think that … particularly with work that’s funded through JHHESA and PEPFAR and UNAIDS, that kind of thing – because they have a very close relationship with the Department of Health, when we do work in that field, the Department of Health takes notice.

So for example last year I did quite a bit of work with a large group of people with different disabilities, on sexual and reproductive health. The Department of Health has a Disability Unit, which is supposed to consider how disabled people can access health services, or how health services can accommodate people with disability. But they hadn’t considered a whole lot of stuff, and so some reports that I wrote last year based on a day’s workshop, including role plays and drawing posters and things, was really leapt on by the Department of Health; and then they were very happy to come on board as a co-sponsor of pamphlets – braille pamphlets particularly for blind people, and – and just looking at … alternative ways of communicating. … Quite a lot of suggestions, as well, in terms of how health workers are working with people with disabilities. I don’t know if those have been taken up, but they’ve certainly all been sent to the Department of Health and read by them. So I think, depending on who’s funding the project and what their relationship is with the Department of Health, that’s what impacts on whether or not it’s going to influence policy.

VH       And from another angle: arts practice. How do you feel you sit within, or you sit against the mainstream of arts practice in this area?

ED       I would say that ten years ago people would consider you outside the arts field if this was the work that you were doing. But I think there is a greater recognition that this is theatre, and this is art … it’s just different from what they’re doing.

… I don’t think people who don’t do this kind of work know how to value it … they don’t know the impact that it has, but they do think that it is slightly less artistic, or that you’re not quite a proper artist if this is the work that you’re doing.

VH       You think that’s still the case?

ED       I do, but it’s amongst a smaller group of people, because the theatre community in particular is just getting smaller and smaller; and more people are realising that you have to do this kind of work to survive in this field. That’s not why I do it; I do it because this is the work that I like to do, and I would rather do than plays in theatres. But yeah, I think there’s a recognition that this is a way for people in theatre to survive, and that’s not the recognition that we want. We want the recognition that this is a valid artform, although slightly different from theatre ‘at the Playhouse.’

VH       At the talk you gave the other day you were making some really interesting distinctions between community theatre, applied theatre, and – I don’t know what you’d call it – ‘High theatre,’ I suppose –

ED       I think I called it ‘professional theatre;’ I was thinking of originally calling it ‘artistic theatre,’ but really there’s as much artistry in applied theatre and in community theatre as there is in that. So … the art of professional theatre is what slightly distinguishes it, the purpose of applied theatre is what slightly distinguishes that, and then the community of community theatre – so the recognition between audience and performer – is what differentiates that from the other two. But there are … so many crossovers, and – they’re become less distinctive, I think; as artforms, they’re becoming less distinctive; and it’s a case of geography, really. Geography and the funders at the bottom of the programme notes, or on the banner that’s outside the clinic.

VH       There was an interesting point about community theatre and how you could have a community theatre production in the same space as a ‘professional’ production and the only difference really would be that the community theatre wouldn’t be able to charge as much of an entry fee.

ED       Yeah … that is really the only difference. And I suppose it’s how people see themselves – how the people who are involved in those projects see themselves. So the community theatre groups will … say ‘we are artists, and we are a theatre group.’ And it’s only when they have greater exposure to ‘professional’ theatre that they then start to say ‘oh, well we’re a community theatre group.’

VH       That’s interesting.

ED       Yeah, it is. It’s a funny thing because you don’t want people to stop thinking of themselves as artists, because I think it’s a valuable thing for them to feel that they are artists. But unfortunately community theatre is seen as lesser than by people who go to the theatre.

It’s interesting. When you look at the National Arts Festival programme – when you apply … you have to note yourself either as a professional production company or a community production company. And I know people who … say ‘we must go and see some community theatre.’ So they choose what to go on the basis of ‘is it community theatre, or is it professional theatre?’ rather than what the content of the theatre is.

VH       It makes it seem a very arbitrary division. I had a – related conversation when I was working with a group of ‘outsider’ artists, who were mostly people who had long-term mental health issues, but they were artists, primarily, in the context of the organisation that I was working for. And we had a conversation about the business of being an ‘outsider’ and how they defined that. And one of them said ‘I’m never going to get into the Tate,’ and I thought ‘well yes, but that doesn’t make you an outsider,’ that’s 99.9% of all artists in the world, ever! So your access to those sort of ‘higher’ bits of the mainstream doesn’t really determine whether or not you’re an outsider or an insider.

ED       … if that’s set as the benchmark, if the Tate is the benchmark, is that what they aspire to? Because you know here if you ask a lot of community theatre artists ‘what do you really want to do?’ they want to go on an international tour. So Mbongeni Ngema was really responsible for finding people from communities who had talent and no training, and then putting them in a big production that went around the world. And … that’s what a lot of young community theatre artists aspire to. So while they say that … they’ve got important messages for their community, and they have a responsibility, they also would really just love to go and sing in ‘The Lion King’ in Tokyo for two years.

VH       Yeah. But I think that’s probably common to most young performers – I think it’s slightly different with visual art. I mean you’d have the same with a group of musicians – if you talk to a bunch of 20 year-olds in a band, anywhere, they’re gonna want to go on a world tour …

ED       Yeah, and headline at Glastonbury –

VH       Exactly …

I’ve got two more questions: one is about funding – because this is the kind of eternal panic that anybody working in arts in health is in: do you feel that the work that you do in a South African context is sustainable financially? You said before that … people are choosing to do this work because it is the financially stable end of the spectrum, but do you think that your organisation and the work you do can be funded, can you imagine it carrying on in perpetuity?

ED       You know, I hate funding. I feel that it’s – I feel that it creates a sense of panic and dependency in organisations that shouldn’t be there. And I wish that there were other models that we could look at.

The work that I do with the PST project, which is all the industrial theatre work, is paid for – it’s a product that is paid for by a factory; … it’s supply and demand, and it’s ordinary economics, and it is completely sustainable. And I feel that that should happen in all of the health spheres. So I feel that somebody – the Department of Health, or whoever it is – should say ‘we need people to know about diabetes, and we therefore need to buy a diabetes play.’ But given the government’s propensity to spend money on other things, I can’t see that happening.

I really struggle with funding, so I don’t really know how to answer that, because more and more … funding from outside South Africa is drying up, because people don’t really see South Africa as a priority country any more; it’s no longer a developing country … – or it’s no longer an underdeveloped country. So it doesn’t classify for all sorts of foreign funding any more.

[And] arts funding is so small, that it is less used on this kind of work, and so the funding that is accessed is health funding or social development funding.

I was talking to somebody who runs a project in Kenya; … what they do is that they sell carbon credits … it’s a water project; … they supply a person in a village with chlorine in a bottle; and you squirt a squirt of chlorine into your bucket of water collected from the river or the well … and then it makes that water safe to drink. And because the product saves so much on shipping in water, or bottling water … they mass up carbon credits, and then big multinationals, who need to buy carbon credits because they’ve just used 40 million carbon credits to build a factory, can offset their costs. So it’s this whole alternative economy… And they’re just starting a new one on social development credits …

VH       So sort of corporate social responsibility stuff?

ED       It is, but it’s beyond corporates that are doing it – it’s governments and it’s all sorts of things. … I think she called it ‘social cohesion credits.’ So if you … do something that causes social cohesion, or brings people together, and helps people solve problems, then you get social cohesion credits. And that’s where we would really be able to tap into that kind of trading. So it’s international trading – it’s like a Stock Market in carbon credits, and now [a] … Stock Market in social cohesion credits.

VH       That’s totally fascinating.

ED       Yeah … because I think it could really revolutionise the way that these kinds of projects are funded. Because it then doesn’t become just about CSI [Corporate Social Investment] funding; it actually is a need on the part of those companies … So that’s what I wish we could get more towards, this kind of trading, rather than – asking for funding, asking for money.

Emma’s new book, co-written with Roel Twijnstra: Theatre Directing in South Africa: Skills and Inspirations, is available by emailing info@twistprojects.co.za.

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