HIV in Botswana: The Case for an Aggressive Approach

As I’ve mentioned here before, I’m in Botswana to work at a pediatric AIDS clinic. Work is going much more slowly than you might imagine. But I’ve spent much of the downtime of the past month learning more about just why what my corner of the clinic does, providing psychosocial support to teenagers, is so important.

First some background on HIV/AIDS in Botswana, which is the second hardest-hit country by the epidemic after Swaziland. Currently, about 17.6% of the population is infected with AIDS, though a decade ago nearly 40% of adults were infected. Compare this with the recent news that Kenya’s HIV prevalence has dropped from 7.2% to 5.6% in the last five years. I often find myself thinking about the peak years of the epidemic in much the same way I think about years of conflict or genocide in Uganda and Rwanda, with the societal impacts (particularly demographics and the long-term effects on the workforce, education system, family structures, etc.) playing out in ways that remind me greatly of post-conflict societies. HIV/AIDS isn’t just a medical problem, it’s a social and economic problem as well.

The government has been highly effective in curbing the devastating effects of the disease. In the early days of the epidemic, infection often resulted in death within a few years. Unity Dow and others talk of social life being overrun by funerals in 2004 and 2005 to the point that people couldn’t keep up, that traditions around burial and ceremony had to be adjusted to accommodate the surge. Life expectancy was under 40 years in the early 2000s; now it is 53. Thanks to the government’s work (in partnership with other organizations and companies) to end transmission of HIV by 2016, HIV testing is something you must now opt out of to avoid, anti-retroviral medications (ARVs) are widely available and covered by public healthcare, and prevention of mother-to-child transmission services (PMTCT) have caused a drastic drop in new cases in children (now only 4% of newborns get HIV from their mothers).

In fact, the government has been doing so well that people are starting to talk about redistributing funding. “These programs are great, but is it still the best allocation of limited resources?” Critical minds in development/aid work (always) want to know. Why pour more resources into eliminating transmission of HIV, an infection with which many people can live long, fulfilling lives, when there are other infectious diseases and rising levels of non-communicable diseases (NCDs) that kill lots of people and do not receive enough attention?

That is a question I likely would have posed before I got here. Not that it is a bad thing to try to stop HIV transmission, I would have hastened to ad, but hasn't there been so much progress over the last decade that we're reaching a point of diminishing marginal returns on investment? I still think there's a lot to be said for re-examining health spending priorities, but here is a non-exhaustive list of some of the points I'd now make in favor of continuing efforts on this front:

1. Children infected with HIV face a significantly higher likelihood of developmental delay than HIV-negative children. Those delays can, in some cases, cause them to slip through the cracks of Botswana’s education system. Not to mention the school they miss or work the adults miss to receive medical care. So not only has the previous generation’s working population been eroded, but also a portion of the current generation of youth is growing up unable to succeed academically or in the workforce.
   

   

   
   
2. Improving HIV/AIDS-related health systems strengthens more of the health network than just the HIV-related components, just as having HIV/AIDS makes you susceptible to a range of other health issues and often complicates treatment for other diseases (e.g. the rise of cancer in Botswana and other resource-poor countries is linked to HIV). The clinic I work in specifically targets HIV-positive children, but provides a broad range of services to them and their families. As fewer and fewer children are HIV-positive, I wonder whether the clinic will expand to adult HIV-positive patients or HIV-negative children. Overall, I expect the health infrastructure that has been put in place to combat the epidemic can be extended to cover more general health services.
   
   
3. Although life with HIV can be long and fulfilling, it’s not easy. Adhering to a strict daily drug regimen—taking your medicine at specific times of the day, with food—for the rest of your life is more difficult than it sounds, and non-adherence can allow the virus to develop resistance to your medications, which makes the disease more serious, for you and for society as a whole.
   
   

It’s this last point that’s most relevant to what I do. Following the implementation of PMTCT programs, the number of young children with HIV is diminishing and most infected youth are adolescents born pre-PMTCT (which was introduced in Botswana in 1999). And adolescents tend to have a hard time with adherence.

Adolescence is a difficult time for people anyways, with trying to prove yourself and establishing independence and rejecting authority and having insecurities and developing new relationships and being overexposed to narratives of what “normal” is—while still negotiating a sense of self to counter those narratives. Hyper-awareness of stigma and the opinions of others can tip the balance for adolescents grappling with issues of disclosure to their partners and others, of taking their medicine regularly when friends and dorm-mates are around, of wanting so badly to be “normal” that they play tricks with themselves (“maybe if I just don’t take my meds it will be like there’s nothing wrong”). These problems aren’t unique to HIV-positive youth.

I think there’s also a really interesting tension in adolescents between, on the one hand, the desire to live in the moment—with greater reward-seeking leading to greater risk-taking—and on the other hand, a growing appreciation of the idea of permanence, particularly among older adolescents. I think (though I’m no psychology expert!) it’s in late adolescence that people start to grasp what they can, and more importantly cannot, expect to change over the course of their lives and what it really means to have a medical condition that will be a part of them for the rest of their lives. And I imagine that can be a pretty scary, desperate place to be at times.

Last Saturday, over a hundred teenagers turned up to the clinic to hang out with other HIV-positive teens and do activities and hopefully learn something about how to have happy, healthy, fulfilling lives and (most importantly) to have a lot of fun. I’m responsible for planning these events every month, and it feels like a big task to shoulder—not because the logistics are difficult, but because I think about all the potentially dark things happening in their hearts and minds and wonder how to break through all that, to get them to healthy adulthood in day-long installations once per month.

Our co-facilitators for the day started off with some song and dance in the clinic lobby, coaxing the kids to mingle, then clap, then turn to their neighbors to say “you’re special”, then make some noise. I saw a girl of about fifteen roll her eyes at her friend. And somehow suddenly the entire room of 144 teenagers and volunteers was jumping and cheering and singing and waving their arms and bursting with impossible grins and in the deafening noise and exuberance, I swear you could feel the joy as a tangible force in the room. These kids were so full of life. I choked up; it was one of the most moving experiences I’ve had.

I don’t want these teenagers to get sick, don’t want them to feel they won’t be loved if they disclose their status, don’t want them to struggle with normality/identity/secrecy/insecurity any more than any other teenager does. And maybe they don’t, mostly – the small discussion group I joined talked about their biggest obstacles being stress over exams, just like any other teenager. But the facts are that adherence rates are significantly lower among adolescents and young adults than they should be.

I watch the teens elected to be leaders among their peers work magic bringing the teens together and taking responsibility to make sure things run smoothly, and I see kids turn up every Saturday for extra tutoring (and wait patiently for me to remember how to explain their basic chemistry problems), and I feel such fierce, affectionate admiration for them. They are what makes my being here worthwhile, and why I want to see what else Botswana can accomplish in HIV/AIDS prevention and treatment.

First impressions of Gaborone

Nearly four weeks into my stay in Botswana, I’m starting to feel like I’ve found my footing and am really getting settled. Unfamiliar pronunciations are starting to roll a bit more easily off the tongue, seemingly-identical intersections are becoming landmarks that help me build my mental map of Gaborone.

Work has been somewhat slow, but I am looking for projects to get involved in. When I’m not working, I’ve been filling my time with braais (barbeques), slowly improving my disastrous frisbee “skills”, camping, cooking and being cooked for—including a glorious eggs benedict breakfast and a Shabbat dinner, finding my way around the combi system, wine tasting at the aspirationally-named “yacht club”, reading, running, learning new boardgames, and, mostly, meeting a lot of fantastic people.

Just outside Gaborone

Botswana is dry. And, because it’s winter, surprisingly cold in the pale mornings. “Just wait ‘til the summer comes,” says every Motswana and long-term expat I’ve met. The sky stretches out blue and blue and blue without even the faintest thought of a cloud, and even the two days so far that have been overcast yielded no moisture. Gaborone is more of a sprawling town than a city, but it’s the largest in the country, so I’ll leave the condescending New Yorker behind for now. The deep pink light of sunset slanting through air thick with dust, the quietly imposing backdrop of Kgale hill rising at the southern edge of the city: these are moments of striking beauty that will stay with me. Botswana is often considered an African “miracle”—a stable, middle-income country with strong government investment in infrastructure, social services and population health. Indeed, I have to say I’ve been impressed.

I’m lucky to be living in a nice apartment provided by the clinic—primarily for American medical residents here to do month-long rotations at the clinic—in a neighborhood surrounded by embassies. So I know I can’t assume my experiences of reliable internet, electricity and running water are at all universal. A quick look at Old Naledi (a high-density, low-income neighborhood that was historically an illegal settlement) and villages just outside of Gaborone, neighborhoods that many of my teenagers call home, certainly makes that obvious.

Nevertheless, I’ve been impressed with the immaculately paved main roads, the relatively easy public transportation, the general quality of building construction, and the potable tap water, and I don’t think my impressions here are too overly biased by my living situation. Even an article critical of Gaborone’s planning, land allocation and development calls the city “extraordinary in African terms… a city lacking in mass poverty, extensive squatter settlements or recurrent civil strife: for all appearances, an orderly, affluent urban area.”

It seems to me that one of the most crucial differences between Accra and Gaborone is population density (about 9,600/km² and 1,500/km², respectively). I notice it in the different textures of daily life, the feel of the city as you walk down the street. Density is more concrete than just noise and bustle: it’s also the traffic that makes everything run late, the restaurants and small-scale businesses that can pop up and slowly grow in unexpected places, and (arguably) greater overlap of rich and poor. And, importantly, it’s the additional wear on infrastructure, including roads, water delivery and electricity grids. Brian Larkin points out that such “material structures produce immaterial forms of urbanism—the senses of excitement, danger, or stimulation that suffuse different spaces in the city and create the experience of what urbanism is.” I can think of numerous similarities between Gaborone and Accra, but ultimately the forms of urbanism in these cities are drastically different.

The simpler explanation for the differing material structures is that Botswana’s GDP per capita is over five times that of Ghana. But I suspect that Gaborone’s public services and infrastructure seem impressive because they endure less wear, and that the cloistering of low-income populations makes it that much easier to extol the prosperity of the rest of the city. These are density-related issues more than financial ones. It will be interesting to see if density rises significantly as the economy further develops and mortality declines (particularly HIV-related mortality), or if the city will rather sprawl.

Jane Jacobs (1961) writes that cities, and creativity and innovation within urban centers, flourish when there is sufficient density for street-level interactions between a diverse array of people. She would certainly prefer Accra to Gaborone, which was designed according to exactly the principles she most opposed. She would also, I think, prefer Old Naledi to Gaborone’s other, more sterile neighborhoods, much as I preferred Kariakoo to Sea Cliff Village in Dar es Salaam.

I imagine a future Gaborone with the same sparsely-populated center and ever more densely-packed neighborhoods around the periphery. Would those densely populated neighborhoods be pockets of collaborative innovation, or would the structural problems of poverty underlying the need for such close quarters staunch such creative vibrancy? A call for better education, health services, and investment in these neighborhoods….

Now that I’ve found my footing, I hope to venture further out of my privileged arena. I’m sure my thoughts on Gaborone’s neighborhoods, infrastructure and urbanism will develop—and probably change completely—as I get to know the city better and from different perspectives.

London Charm and the Colonial Legacy

I landed in London, over a week ago now, and felt an irrepressible grin take hold of my face. The reality of my latest journey having truly begun, after months of planning (nearly a full year since I began my application for this program), finally sank in as I walked through Heathrow. But that was only part of my excitement: I was in London.

I would never have expected to be so excited about visiting this city, but I guess over the last several years of reading the BBC, watching British tv shows, becoming increasingly familiar with the culture, and meeting many wonderful people who had claimed the city as home at one point or another, I’d worked up a subconscious curiosity about it. The U.K. is easily the country I know most about of those I’ve never visited. Without my realizing it, it’s been in the background of my mind as a sort of friendly “Other”, a reflection of my own country—or some sort of parallel universe. London and New York, the U.K. and the U.S. occupy similar spaces for most of the world, and yet there’s a distinct identity (primarily reinforced by them). Comparisons between the two places abound.

As I navigated my way to meet up with a friend, I walked into a place that had only existed in my mind. I paid for my ticket with POUNDS! I was on THE UNDERGROUND! It was charming and small! I emerged from the station and all of the buildings around me were stunning and I was in awe. Give me a few years in this place, I thought. Let me repeat: I had zero expectation of feeling this way. But I recognized my behavior. It was the same as someone from another country visiting the U.S. for the first time and seeing the iconic NYC sites and recognizing that, yes, this was the place in the movies and books and news. There’s something about being, in the flesh, in places that permeate our culture and our imaginations for years before we visit in person.

I was thinking about how the U.S. holds that position for many people around the world, and how it’s our cultural hegemony that engenders such widespread curiosity and desire to come to the U.S., not just hopes for prosperity (even if this is commonly expressed). On the other hand, I was also thinking about how different such a trip would be for someone coming from a developing country or the Global South. In my case, patriotic narratives and America’s global stature easily counterbalance British critiques of the U.S., but many others would have been told implicitly or explicitly that this other, more powerful country and culture was superior to theirs. The internet and other new technologies both challenge and reinforce this dynamic.

On that note, I thought of this beautiful letter on decolonial aesthesis from a Singaporean woman to her younger self about her experiences studying at Cambridge University. How many people would feel, in the face of Britain’s imposing cultural stature, as she did: “There’s not much culture [where I’m from]… There’s not much nature”? She writes, “[Colonialism] happens these days not by the strength of arms or the power of states, but by the captivation of the eyes, the training of the taste, by unwritten rules of thumb – that we all learn everywhere, without even knowing it.”

A recent map showing all the countries Britain has invaded reveals the global spread of its potential cultural influence. Source.

My entire time in London, I didn’t think for a moment about the fact that Botswana had been a colony of the U.K. That even if Botswana wasn’t itself Britain’s most lucrative colony, it was still part of a structure that gave the country wealth and power in the international arena, that had helped install British culture as a dominant aesthetic. Botswana had made London lovely, and I didn’t even notice it until I had landed in Gaborone.

When I left Ghana last year, I had a layover in Amsterdam, where I was also charmed by the beauty of a European city. I stopped into the Rijksmuseum and saw a portrait of a couple that had been based in Elmina, Ghana. The placard announced that they’d worked for the Dutch West India Company, which traded in gold and slaves from Ghana for nearly 300 years before the British took over. I remember the jolt of connecting the two sides of the same story, having seen the slave forts and trading posts owned by the Dutch in both Ghana and Benin. A recent AIAC post on Dutch denial/ignorance of their historical slavery practices notes that less than half of Dutch history textbooks in a recent study so much as mentioned slavery, and even in those, the emphasis was on hardships the Dutch colonists suffered, rather than those of the slaves. Walking through that museum less than a day after leaving Ghanaian soil, I was taken aback by the normalization of this terrible history and the narrow-minded focus on what the Dutch got out of this trade, the nostalgic pride in the Dutch empire at its peak. Ghanaians certainly hadn’t forgotten the price of that empire.

In Gaborone, I stood on my new balcony and looked out at the dusty scrub in the afternoon sun and crisp, dry air, wondering at the difference in my reaction to arriving here. I was excited, exhilarated and absurdly happy, to be sure, but the truth of it was I just didn’t know Botswana and its cultural references as I did the U.K., and that’s a sad fact. Normally the lure of exploring the unknown is a huge part of the joy of travel, but I’d sampled another style of encountering a foreign place the previous day and I couldn’t help but feel I was missing out. What would it have been like to feel in Gaborone that same sense of arrival in a mythical place?

Botswana challenges popular notions of “Africa” – including my own, based on previous travels. (This is not terribly surprising.) The airport lacked that smell of heat and fruit and human bodies that has greeted me in Uganda, Tanzania and Ghana. Sometimes I think I’m in Arizona. The city, like the rest of the country, is sparsely populated and the lack of traffic, the lack of bustle, the relative lack of streetside vendors throws me off a little. The clinic is, as my housemate said, “nicer than any clinic [she’s] seen in the U.S.” and the teens I work with would fit in at your typical American middle school. I live in a wealthy area, and have only been here a week, so my perception is drastically limited, but I like that I’m forced to re-evaluate perceptions of the continent I didn’t quite realize (still) I had.

I’ll end with a quotation from that letter preparing the Singaporean girl for life in a new culture.

Modernity is someone saying to you: look, we have made you better. And you believing it.

But the question is not how to retreat or how to prune yourself back to some pristine, native state. In fact, it is the opposite: how to recognize the narrowness of this so-called broadened mind – to realize that Europe is not the universe – and to take your sensing and knowing beyond those dominant ideas of the true, the good, and the beautiful. To move towards a pluri-verse that gives dignity to both the girl in the pajamas and the one in the little black dress – and yet to do so in a way that, unlike Western liberalism, is not naïve about either the ‘equality’ of the two, or about how we got from the one to the other.

I loved London, truly, but I don't want to lose sight of its context. And I look forward to wondering at all that makes Botswana magnificent.

 

Setting out on a new adventure

Welcome back to the latest incarnation of my blog, which I hope will be more active than the last. I write this from my new apartment in Gaborone, Botswana, where I will be living and working for the next year. Before we dive into Gaborone and my plans for the coming year, though, let me back up and explain why I’m here.

During my year in Ghana working with students trying to go to college in the U.S., I had a chance to finally dip my toes into something approaching “development work” in Africa—just what I always wanted. Over the course of the year, I had my share of disillusionment with the project (though I also came to see why the organization had chosen the strategies that it did), but there were a couple of things that I found particularly rewarding. I loved getting to know the students, through conversations and their essays and their aspirations for college. It was also a job that played to my strengths: I understand far more of the American college admissions process than your average African student, and I can comfortably say I wasn’t doing work that a local person who better understood the nuances of the local social, political and cultural context could have done better (more on this later).

So as I began to think about future directions, I knew I wanted to have a skill set that would make me valuable even as a foreigner, and that I’d like to work directly with people. On a recommendation and a whim, I checked out a public health master’s program, and realized it was exactly what I wanted. There’s something very concrete about working in medical fields, but I hope that there will also be room in public health for attention to the political and cultural influences/outcomes.

This year, I will be working with HIV-positive teenagers at a clinic in Botswana. Many of my roles and responsibilities will likely change over the course of the year, but generally my job will be to support the teenagers in building healthy, happy, productive lives.

I’m entering this new stage with a lot of questions in mind, mainly about how to do the best job possible. I’ve recently read Susan Wicklund’s This Common Secret: My Journey as an Abortion Doctor and Tracy Kidder’s Mountains Beyond Mountains. The first is the memoir of an abortion doctor working in Wisconsin, Minnesota and Montana, and the second is a biography of/love letter to Paul Farmer, the public health superstar physician who began Partners in Health.

At one point in the second book, Farmer is quoted as saying that “it’s not about a quest for personal efficacy” —that is, we should focus not on improving ourselves, but on improving the lives of others. Of course, true selflessness is impossible, since we gain something from helping others, even if it’s just a brief easing of moral discomfort, but the quotation struck me. If we’re focused on improving the lives of others, shouldn’t we make sure we are doing the best job of it as possible, and isn’t that a question of personal efficacy?

Kidder follows up with an explanation from one of Farmer’s colleagues, who says that the doctor represents a model of what should be done—proof that extremely difficult problems can and should be addressed—rather than a model for how it must be done. I think the same could be said of the abortion doctor. Focusing on trying to be Paul Farmer or Susan Wicklund is not important (and certainly there are many criticisms to be made of both). Nevertheless, they do both present a model for improving the lives of others, and share an intensity in their passion for caring wholly and specifically for the individual patients in front of them that I would like to carry with me as I begin this new job.

It’s really important to think about systemic problems and large-scale changes that need to be made (and, indeed, both doctors are engaged on this level as well), but without a focus on the individual, you perhaps risk allowing those systemic problems to overwhelm you. They might become an excuse not to act at all. Both doctors share concerns about the costs of losing sight of the individual, and Farmer in particular is presented as being afraid of allowing work on large-scale issues—like international advocacy on treatment procedures—to crowd out seemingly less impactful tasks, like day-long trips to see a single patient. At least as a starting point, I think it’s worthwhile to have a grounding in the personal and the specific from which to build a broader political awareness/advocacy agenda.

It will be hard, much harder than I’d like to admit, to fully relate to the patients I will work with and to consistently see through their eyes. I come from a vastly different cultural background, and from a position of both absolute and relative privilege: can I really hope to understand the perspectives of HIV-positive Motswana teenagers? I look forward to holding myself to the challenge of doing my absolute best to listen and learn from them, and to use what I learn to make whatever improvements for them possible.

This clinic is at the top of its field, and I know I have so much to learn from my experiences here. I hope that the lessons I learn will help me wherever and with whomever I end up working, but for now I would like to put thoughts of my own future aside to concentrate on the lives of these teenagers. Wish me luck!