At times the Princess Marina Hospital resembles a mini-United Nations, with Cuban, Egyptian, Chinese, and Ukrainian accents mixing in the wards with the local English and Setswana. Until recently, Botswana has had no medical school, and most of its doctors hail from other places. (“One of our earlier years there we had a holiday party and asked everybody to bring a dish from their home country,” Gluckman says. “That’s where I got an idea of how many home countries there were.”)

With the low salaries it pays, the government has had little luck luring home the citizens it sends out of the country on full medical scholarships. “The government policy has been that as soon as they get done with medical school, they return home without any formal postgraduate training, do a year of internship—apprenticeship, one might say—at one of the two referral hospitals in the country,” Sebonego says. “After that internship they are posted to hospitals around the country as medical officers … They just learned on the job. Nothing was standardized. They were just thrown into the deep end, and it became sink or swim.”

That’s one reason Penn’s presence has been so helpful, he says. “Through Penn we are able to temporarily get specialties and sub-specialties such as neurology or dermatology that we do not have in government hospitals … some of which do not exist in the entire country.” He’s glad to see that situation slowly changing with Penn’s development of an accredited internship program there.

“I think it is going to have a lot of positive impact on the quality of young doctors coming out of school to work in Botswana,” Sebonego adds. “For the first time their teaching will have a formal component.”

 

“AIDS in Africa is not a medical problem,” Gluckman says. “It’s a social and economic problem.” Botswana, a former British protectorate that became independent 40 years ago, has a progressive government with good economic resources. “South Africa has resources, but it’s mostly had a government in the way [of fighting AIDS]. Zambia has a reasonable government, but [few resources]; Namibia has neither. Each country has its own issues, and it’s incredibly naïve to blame the problem on a lack of being able to afford the medications.” In fact, he says, without a medical infrastructure to effectively manage the disease, from the pharmacists to the lab technicians and the nurses, the medicines are worse than useless. “If you screw up, the virus becomes resistant.”

Fortunately, that infrastructure is growing in Botswana. In a few short years, for example, it went from having one clinic dispensing antiretroviral drugs (at PMH, now one of the largest HIV clinics in the world) to 32 such places around the country.

Gluckman also commends the government’s decision to automatically test for HIV anyone who comes to the hospital unless they opt out—a recommendation only recently made by the U.S. Centers for Disease Control and Prevention. “If you use informed consent”—testing only those who have undergone prior counseling—“you’re making the disease special and more stigmatized,” he says. “You don’t get informed consent before you test someone’s liver.”

As a result of the extensive testing and widespread availability of antiretroviral drugs, about 70 percent of the people who need treatment are receiving it, compared to an average of only 10 percent in all of sub-Saharan Africa.

According to one measure, the prevalence of HIV among Botswana’s adult population dropped from 38 percent just a few years ago to 34 percent, says Friedman. And among 15-19 year olds, it has fallen 5 percent, to about 14 percent of that population.

Then there are other signs of hope that are less easy to quantify: “A few years ago the coffin makers couldn’t keep up with the demand, and now they can,” Friedman says.

HIV patients are also coming into the clinics less visibly sick than they used to, according to Sebonego. Still, he worries. Over the long term, he wonders if the funds for the costly antiretroviral drugs will dry up. He thinks more emphasis should be placed on prevention. “I just hope my countrymen could adopt the ABCs, as have been preached: Abstinence, Be Faithful, and Condomize. That would make a heck of a difference with regard to the incidence and prevalence, I think.”

That message is being sent—on billboards and in school texts, but it’s not necessarily getting out, says Dr. Bagele Chilisa, a University of Botswana professor and HIV/AIDS-prevention researcher. One problem is that most communications are in the country’s official language of English instead of the national language of Setswana or any of the minority languages. But the communication is ineffective for another reason, Chilisa says: “It’s the language of the laboratory … We’ve tended to teach the biomedical facts about HIV/AIDS, but what the children and people know are the experiences of suffering and pain, and all that goes with it.”

Dr. Loretta Sweet Jemmott GNu’82 Gr’87, the van Ameringen Professor in Psychiatric Mental Health Nursing, and her husband, Dr. John Jemmott, a professor at the Annenberg School for Communication, have spent 15 years working on AIDS prevention. They hope to adapt their research in the United States and South Africa to bring “culturally appropriate interventions” to the adolescents of Botswana. “How do you get people to see themselves at risk, and then to negotiate safer sex strategies?” asks Sweet Jemmott, who worked with at-risk African-American adolescents and their mothers on similar questions [“And Still I Rise,” November 1997].

“The biggest challenge in southern Africa is that sex is such a big taboo,” John Jemmott says. “It’s an even bigger taboo than in the United States, where parents are reluctant to talk to their children about sex.” If sex can’t be talked about, things like condom use can’t be negotiated, which puts women at a greater risk in this male-dominated society.

“Men have the final say. And men decide when to have sex, and how to have sex,” says Chilisa. “Especially when you are married.”

The ABC strategy is not always realistic, UB’s Musa Dube adds. “Whether you can practice the ABCs depends on the gender power you have in your relationships. If she’s suspicious that her husband is seeing someone else, that doesn’t mean she has the right to have her husband put on a condom.”

The older women might even take aside a new bride and give her some advice: “They’ll say her husband might not be home some evening,” John Jemmott says. “When he comes home in the morning, she should prepare a bath and breakfast, but she should not ask where he’s been. If he beats her and she gets a black eye, she should say she got up in the evening to go to the toilet and walked into a wall. Neither infidelity nor battering are grounds for leaving her husband.”

Poverty, and high unemployment, also feed the disease. Dube talks of Botswana’s sex-workers, saying, “Even if you’re preaching abstinence, even if they know they should be using condoms—if they’re hungry, they’re hungry.”

COVER STORY :
Prognosis Botswana By Susan Frith

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©2007 The Pennsylvania Gazette
Last modified 03/01/07