Re Batla Botshelo! (We Want Life!)

A brief note: When I sit down to write about something like the Health Trip, the most challenging thing to do is to narrow down my topics. I could spend pages just telling you about the elders, the dessicated little San ladies with their sharp, critical eyes and their myriad wrinkles. Wrinkles I never knew could exist, wrinkles going every-which-way... Or the children, who at 5 years old dance better than most white guys can ever hope to, and why they generally stop going to school at about 13 or 14 years of age... Or the shebeens, where everyone gulps down cardboard cartons of a horrible thick sorghum liquor called khadi, and dances the night away. But I have to narrow it down.

THIS ENTRY: Description of HIV/AIDS in Botswana, linkages to TB. The challenges of getting people to be tested and have safe sex, efforts of the workshops. This first part is a bit boring, a lot of background information; the second part covers how the people reacted to the workshops, and their desire to take charge of their own health and their own lives. Description of workshop atmosphere.

CREDIT: Information taken from Wikipedia's HIV article.

When I was in Victoria for the summer of 2005, I made two new friends; both were about 45 or 50 years of age, and both had lost several very close friends to AIDS. Their friends had died in the early 90s, back when HIV/AIDS was still a new disease and the anti-retroviral drugs we use today didn't exist. Back then, HIV slapped you with the terrifying, irrevocable sentence of an early death. People were just becoming aware of it, and there was nothing you could do about it. I remember listening with horror as my friends described the helplessness, the pain of watching their friends' immune systems crumble, their bodies ravaged by opportunistic infections. “It wasn't like cancer,” one of them told me. “I've seen people fight cancer – if you have a strong will, if you have treatment, you can fight it, there's something you can do – but not with this. No matter who you are, how you fight, it will kill you. You never have a chance."

Of course, HIV has not yet been cured. Nonetheless, the face of the disease in modern-day Botswana is quite different from Canada in the 1990s. In some ways it is much more hopeful, and in some ways much more dire. The HIV infection rate is terrifyingly high – in Gantsi district, the estimate is between 25% and 30%. But the Botswanan government provides antiretroviral treatment, free, to anyone who tests HIV positive. Highly Active Antiretroviral Treatment, or HAART, was first made available in 1996 – essentially, it's a cocktail of drugs that inhibits the virus's ability to replicate itself, thus dramatically slowing the progression from HIV to AIDS. According to the best estimates, HAART triples the average length of time that a person lives from the time of infection, giving them about 30 years instead of 10. (There are a plethora of factors affecting how long someone will live after infection, of course – it can be much shorter – but as a rough average, it is 10 years without treatment, and 30 years with HAART treatment, as long as the treatment regimen is adhered to.)

This is an incredible luxury for the developing world, made possible by wealth of the Botswanan government – most countries cannot afford to provide treatment to even a small fraction of their citizens, because of how expensive it is. But here in Botswana, everyone can have treatment – everyone has the chance at a vastly increased lifespan. The problem, then, is overcoming the stigma attached to the disease, and educating people about prevention, testing, and what to do if you know you are positive. When you think about the actual chances of being infected with HIV, it becomes obvious that despite the best efforts of enthusiastic condom campaigns, and the millions poured into education, that the vast majority of people are not doing anything to prevent HIV infection. Most cases of HIV in Africa are the result of heterosexual intercourse, and the chance of infection (with penile-vaginal intercourse) is 0.1% for women, 0.05% for men. Contrary to what many people think, HIV is not that easy to catch. (To clarify – I'm not advocating we all rush off to have a lot of unprotected sex, I'm just trying to make a point about how much we need further education about HIV transmission.)

The main aims of the health workshops are (1) To educate about transmission and prevention of HIV/AIDS, including some hilarious condom demonstrations for both female and male condoms, featuring audience volunteers (2) To encourage people to get tested, both so that they can stop spreading the disease to their partners, and so that they can get treatment to increase their lifespan, (3) To educate about healthy living in general, personal hygiene and nutrition, etc, and (4) To educate on all topics covered for HIV/AIDS, but with respect to TB.

.....TB. Tuberculosis. A disease I remember reading about a lot in Lucy Maud Montgomery books – consumption, a disease that Anne of Green Gables might have been worried about, but I certainly wasn't. Think again. TB is one of the biggest killers of people in this area, and all throughout sub-Saharan Africa – it is one of the most troublesome opportunistic infections for people infected with HIV/AIDS. Many people carry the Myobacterium tuberculosis, but only in a latent state; a healthy adult's immune system can fight it off. However, for someone whose immune system has been compromised by HIV/AIDS, TB poses a serious risk, and because it is highly infectious and people here live in such close quarters, with little understanding of disease transmission and the importance of personal hygiene, it is often transferred to babies and young children and even other healthy adults.

TB, unlike HIV/AIDS, is completely curable – the treatment course is long and unpleasant, but if adhered to, it eradicates the disease. The problem is, again, getting people to (1) get tested, (2) get treatment, (3) STICK TO THE TREATMENT. With both TB and HIV/AIDS, there is a stigma attached to the disease, and many people would rather languish in their homes rather than get tested and have people know for sure that they are infected. The understanding of treatment is shaky at best – so many people begin the treatment, but stop as soon as they start to feel better, leaving their settlement and their clinic to go work on the farms and ranches where treatment is not available, but employment is. They believe they are cured, but without following through with the full treatment course, they will stay infected. Worse, they develop drug-resistant TB. If they begin treatment again, they must take the second line of TB drugs. Some people default on treatment a second time, and then they develop MDR-TB (Multiple Drug Resistant TB), which makes treatment very difficult indeed, and also means that if they infect anyone else, they pass on the MDR-TB instead of ordinary TB. Often alcoholism contributes to patients defaulting on their treatment. In the health office, a lot of people consider TB to be a more pressing threat than HIV – it kills much faster, and it is much more contagious.

Needless to say, I've heard a lot of sad stories over the past few days.

But equally, I have heard stories of hope, and I have witnessed the communities' determination to learn about these diseases and improve their condition. For every person hiding in their home, coughing up blood but too afraid to go in for testing, there is another person who trudges down the dirt road to the clinic to attend the workshop, sit through hours of presentations in a language (Setswana) that they don't entirely understand, so that they can learn about these diseases and learn how to help themselves. The workshops were lively, even raucous at times, full of laughter and eager contributions from the audience. I tried many times to imagine the same workshop taking place in Canada – it would be so much more sterile, quieter, hands raised politely, everyone a little bit worried about how their questions would sound.

In one of the condom demonstrations, M chose two ancient old ladies to show the audience how to properly put on a male condom. Decked out in a strange assortment of vibrantly patterned dresses, shawls and shirts, these two old crones creaked to their feet and stood up in front of the audience. They had so many wrinkles their eyes were barely visible, and their leathery, deeply-creased hands seemed too stiff to do such a delicate thing as roll on a condom. The audience was hooting and shouting, laughing till tears came to their eyes. But, bickering with each other about the best method, they did it. The taller of the two ladies held the penis model and barked instructions at the shorter one as she tore open the packet, carefully pinched the nipple at the top of the condom, and slowly rolled the latex down the resin shaft of the penis replica. She squinted at her handiwork and stood back, looking impassively at the ready-for-sex penis. The crowd went wild.

There was a delightful sense of family congeniality about the whole thing – women brought their babies, because who has daycare in the middle of rural Botswana? Without the slightest inhibition, they popped out their breasts and fed their children, eyes still fixed on the presenter. One young boy kept peeing on the floor – no problem, someone just grabbed a mop and wiped it up without interrupting the presentation. (Let us ignore for the moment the sanitary concerns of having someone urinate on the cement floor right outside the clinic... There was slightly more of a hullabaloo when the same child started to relieve himself of solid waste.) People shouted their encouragement to people answering questions, and openly shared their opinions and concerns. There was a tremendous bravery about it. We don't want to look away from the problem. We admit it's there. We want to know how we can help each other, how we can help ourselves.

On the day I returned to D'Kar, dusty and exhausted, I was walking down the road with the leader of the Komku health team, and we stopped to talk to a woman who was on her way to the bus stop. She had been a participant in a very special beauty contest that took place in Ghanzi a few weeks ago – the “Miss HIV-Positive” beauty contest. “I am on my way to Ghanzi to celebrate fourteen years of being HIV-positive,” she told me proudly, holding a small suitcase, eyebrows dramatically pencilled in, lipstick bright on her lips. She had the unassailable confidence of someone who knows the facts, has looked death in the face and decided to wring the absolute best out of the rest of their life.

There is hope.