In the coal-mining township of Maamba, Leonard is living with HIV/AIDS. He may know it. He may not. There is no HIV testing in this impoverished corner of southern Zambia, where health professionals fear that 30 to 40 per cent of the population could be infected but those who are rarely admit it.
Rather than AIDS, they have tuberculosis or skin disease or fungal infections. They acknowledge only the symptoms.
Leonard (not his real name) has TB and the Zambia Red Cross volunteer who cares for him monitors his medication and does all she can to ensure a proper diet. She must tread warily as she prepares to discuss his root problem.
"You have to pick the right moment," says 39-year-old mother of five Phoebe Silungwe. "Wait for a mood that makes it possible." Leonard is an intelligent man and she believes he knows the truth already. He has, she thinks, been in denial but having won his trust she hopes he will himself now raise the question.
With 1.2 million Zambians known to be HIV positive, among them over 21 per cent of adults, Maamba reveals a parlous state of affairs, a sorry reflection on the political will and resources made available to fight the African pandemic.
Health facilities throughout the country are over-stretched and under-funded, and this district's needs go beyond support for testing and counselling. Essential drugs are sometimes missing. It isn't just life-saving anti-retroviral programmes, accessible to all in the wealthy world, which are out of reach. The supply of basic drugs needed to treat opportunistic disease can be interrupted.
At Maamba's 250-bed hospital, serving a district of 150,000 people, executive director Isaac Kasaro agonizes over budgets. "If we had a constant supply we could prolong life and ease the suffering," he argues. "The demand is so huge we run out of things and that endangers our patients' lives. At the moment we are out of the drug we use in TB relapse. There is none in this region and TB is the most widespread of all opportunistic diseases."
Since becoming ill in 1997, Leonard has relapsed three times and acquiring the drugs he needs has often been a struggle. When available, TB medication is free, but other drugs must be paid for. Doctors issue prescriptions and patients buy from private pharmacies. With the coal mining industry in serious decline and unemployment high, few can afford it and even if they can the district has no pharmacy. The nearest source of drugs is Lusaka, the Zambian capital, more than 400 kilometres away.
Help has come to Leonard from a Zambia Red Cross integrated home-based care programme, funded through the International Federation. The scheme supports 239 township households where someone is suffering from AIDS-related disease. Working closely with the hospital, which identifies the clients from clinical evidence, it provides medication and food, care and counselling, and has served as a pilot for Red Cross programmes elsewhere.
Growing steadily, it faces enormous needs. Dr Kasaro, who is social advisor to the Zambia Red Cross and a member of its national executive, spells it out. "I would say 40 per cent of the population this hospital covers are in need of home-based care. Right now the programme is limited to the 11,000 people of the township but it is imperative it reaches into the district." More care facilitators like Phoebe Silungwe are being trained, and plans formulated.
Less than a year in operation, the programme's immediate aim is to spread within a radius of five kilometres around the township. Margaret Siatwinda, the Red Cross project officer, says, "We are moving as fast as resources allow. The farther away the villages are, the worse the situation, the harder it is for people to cope."
The truth is there is no health care for many rural people. They can walk for hours to reach the nearest clinic, which is understaffed, often with poorly trained people, and poorly stocked with medication. Some dispense little more than aspirin. There is no outreach service and the sick and immobile are frequently left to their own devices. The government has attempted to widen health-care access by decentralizing services, but the need is overwhelming.
Meanwhile, Leonard struggles even in the township and he calls the Red Cross programme "manna from heaven". Without it not only he, but his family, would be in more dire straits.
Poverty bites. Soon after falling ill in 1997 he was made redundant from the failing mine. One day he had a well-paid job, the next day no income because the mine could not afford redundancy payment. The government has shouldered the burden but only advances a small amount from time to time. Leonard and his wife have seven children to feed, clothe and educate and it is doubtful that they can manage much longer.
Red Cross coverage of other needs does ease the burden. Besides the medicines and vitamins he needs, food from the International Federation's Southern Africa Food Security Operation is a vital component of the Red Cross programme.
People living with AIDS are among the most vulnerable of the three million Zambians needing assistance in the continent's enduring food crisis. Good nutrition is essential to resist the illness, and ward off early death, and without food even the taking of medicine is difficult. "When you don't eat, the drugs make you sick," Leonard says.
Some people cannot face it and interrupt their treatment. Margaret Siatwinda reports that since food was introduced to the programme, clients have retained better health, and early death is less frequent.
A long struggle lies ahead, one that calls for the introduction to Maamba of HIV testing and counselling. "There is tremendous ignorance here of who is infected," says Siatwinda. "For people to be helped, and to protect their loved ones, they have to know what is wrong with them."