Botswana

Saturday is for funerals

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JOHANNESBURG, 18 January 2012 (PLUSNEWS) - One part novella and two parts textbook, Saturday is for Funerals* [ http://www.hup.harvard.edu/catalog.php?isbn=9780674050778 ] pairs the recollections of Unity Dow, five-times author and Botswana's first female high-court judge, with the analysis of Harvard health sciences professor, virologist and chair of the Botswana-Harvard AIDS Institute, Max Essex.

As Essex notes, Botswana is typically held up as one of the first African countries to boast early successes in tackling HIV. Although HIV prevalence remains high, with about one in four adults living with HIV, it has been particularly hailed for the early political will shown by leaders, such as former President Festus Mogae, in addressing HIV.

Under Mogae, Botswana introduced prevention of mother-to-child HIV transmission (PMTCT) services in 1999 and almost six years later was able to boast that these services reached as many as 90 percent of all HIV-positive pregnant women.[ http://www.plusnews.org/report.aspx?ReportId=74389 ] He also introduced antiretroviral (ARV) treatment by 2002, at a time when former South African president, Thabo Mbeki, was still questioning the link between HIV and AIDS, and his health minister, Manto Tshabalala-Msimang, was describing ARVs as "poisons".

Botswana's national PMTCT programme had been under way for four years when South Africa finally launched its PMTCT programme in 2003, after a protracted legal battle with the Treatment Action Campaign, a lobby group.

Changing times, changing lives

Rising HIV prevalence rates in the 1990s meant big changes in Botswana. By 2000, writes Essex, the World Health Organization had issued dire warnings: 85 percent of 15-year-olds in the country would die from AIDS-related illnesses; life expectancy would drop by 44 years.

But Dow recounts the more insidious and poignant changes, the ones that crept into people's daily lives and culture as deaths mounted before ARVs were available.

"If you have not seen someone for a while and you meet their mother, you are afraid to ask after them. Perhaps they have died and you have not heard," writes Dow, recounting the words of her mother. "It was never like this before. You must remember people's children and be sure to ask how they are. How can you ask about people who may be dead?"

The title of the book itself points to the way rising AIDS-related deaths meant funerals became a weekend fixture. So much so that the cultural practice of midnight grave-digging had to change to meet growing demand. Young men could now be seen digging graves in the afternoons as well, Essex notes.

Dow recounts how, as an advocate for women and children, she became an HIV resource for friends, family, strangers and, as a high court judge, those in her courthouse. When most still will not name the virus, her directness in approaching the subject is appreciated, she writes.

In each chapter, Dow's prose is followed by Essex's medical review of the issues encapsulated in Dow's vignettes. Untrained experts will likely benefit from Essex's scientific explanations, particularly of ARV resistance and side-effects. However, there are gaps. He fails to distinguish between traditional and medical male circumcision: some forms of traditional circumcision may not remove enough of the foreskin to offer protection from HIV infection. In clinical trials, medical male circumcision has been shown to reduce a man's likelihood of contracting HIV through vaginal intercourse by up to 60 percent. [ http://www.plusnews.org/report.aspx?reportid=94604 ].

His explanation of clinical trial procedures is a welcome addition, especially when read against the backdrop of mass media reports that in southern Africa continue to portray participants as "guinea pigs". However, his assertion that it is important to encourage HIV vaccine trial participants to avoid pregnancy not only because potential vaccines have not been tested for safety in pregnant women but because "additionally it seems important to strongly discourage pregnancy for HIV-positive women, whether in trials or not, to prevent the risk that more HIV-positive infants will be born". Such arguments have resulted in alleged forced sterilizations of HIV-positive women in Namibia and South Africa, despite the fact that PMTCT services are available. [ http://www.plusnews.org/report.aspx?reportid=85012 ]

Essex's wording around migration is also likely to spark some discontent: "Refugees and immigrants from all over southern Africa see Botswana as the place to be. This obviously increases tension, as well as demand on programmes with limited resources."

Despite the fact that migration has been a facet of southern Africa for centuries, contributing to the region's high burdens of HIV and tuberculosis, migrants continue to face challenges in securing cross-border healthcare. While the Southern African Development Community has reviewed the idea of health passports to address this, there has been little progress. As recently as August 2011, the Botswana government was reportedly refusing to treat HIV-positive foreign nationals in its prisons.[ http://www.mmegi.bw/index.php?sid=6&aid=935&dir=2011/August/Friday12 ]

In addition, the number of migrants remains difficult to estimate and research from South Africa and other countries shows that it is often migrants who wait until it is too late to access care. [ http://bit.ly/wpWgrh ] Many foreign nationals in Botswana are likely to have come from countries such as Zimbabwe and Zambia, which have lower HIV prevalence rates.

Despite such shortcomings, Saturday is for Funerals manages to provide a window into how HIV changed one country that largely seemed to "get it right" when confronting HIV and AIDS while providing readers with the scientific background to understand how and why many of the issues faced by Botswana continue to challenge that country and many others. If nothing else, it is an addition to the ever-evolving story of HIV in which, as its authors note, "understanding how people live and love is the key to understanding how and whether the science breakthroughs will work, and how to redesign them so they will work better".

*Released as a paperback in 2011

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