The HIV/AIDS Pandemic: suffering in silence

Larry A. Swatuk | Wednesday March 21, 2007 00:00

Mainly because of the AIDS pandemic, life expectancy at birth has plummeted across these countries. A person born today can expect to live to age 35 in Botswana and Lesotho, 47 in South Africa and Namibia, 38 in Zambia, 37 in Zimbabwe and only 31 in Swaziland. Something must be done and that something, I believe, is breaking the silence that surrounds the disease. But we are talking about it and taking action, you might argue. True, there is a lot of public rhetoric attached to HIV/AIDS, but we are silent where it matters most - we are silent about our own status, particularly at the level of top leadership in SADC countries.

The stigma attached to this disease has never been clear to me. In Africa, HIV/AIDS is truly democratic - it affects people of all classes and races and of both sexes. We are all susceptible. We all know someone who is either HIV positive, or has full-blown AIDS, or has died from the disease. We share the pain. So, what's the big deal? Why can we not openly share the experience? Yet, in most rural areas, people who need treatment are afraid to go to clinic, knowing that their neighbours will point fingers and say 'that one has the slimming disease, he/she must be shunned'.

People in rural areas, in inner cities, the least educated, the most superstitious, in my view will only begin to regard the disease differently if and when they see their leaders doing the same. And while there has been much pressure put by activists on leaders to reveal their HIV status, by and large they remain silent. Why? The answer, it seems to me, lies in the nature of the health care system, itself reflective of deeply unequal societies.

Formally, we are said to have a two-tier health care system. There is the public hospital and clinic available to everyone for a small fee. There is also the private hospital where better and more diverse treatment is available but at a significant cost to the patient. In my view, this is only part of the story. In fact, these two tiers constitute the middle of what is really a six-tier medical system. The traditional healer - the man/woman of the village and of the urban poor, constitutes the bottom tier. The second tier is the rural clinic that, in truth, is mostly little more than an aspirin dispensary. These two tiers are clearly inadequate to meet the basic needs of the people they serve, let alone deal effectively with the HIV/AIDS pandemic. Yet 'home based care' most often relies on these tiers. This is why HBC in my view really means 'go home and die'. The third and fourth tiers I have already described. The public and private hospitals those are available to a majority of Batswana. However, public hospitals across the country and throughout the region are notoriously under-resourced. They often act more as nodal points on disease vectors - places of transmission rather than cure - than successful and dependable sites of medical treatment.

The private hospital is available to a lucky few. That is to say, all those with medical aid packages and a disposable income above subsistence living. Across Southern Africa, 70 percent of all people live on less than two U.S. dollars per day - hardly enough money for adequate medical care. In private hospitals, performance is directly related to available income - the better resourced the hospital, then the better the care a patient will receive. In small countries such as Botswana, Lesotho, Namibia and Swaziland, the numbers of those who can afford such treatment, and the numbers of those who in fact need hospital-based medical care at any one time are extremely small. So, even private hospitals in these countries face serious financial resource constraints.

What is a sick person to do? If you are among the employed elite, you have two further options - fly to South Africa (tier 5) or fly to Europe/the UK (tier 6). It is a telling indictment of African medical care systems that the sixth tier is the 'tier of choice' among African leaders. For Africa's elite, rather than develop a first class system locally - admittedly, a collective endeavour neither easily achieved nor readily sustained - the answer seems to be 'better to look after myself and my family, and damn the rest to their own devices'.

This multi-tiered system, among other things, in my view, allows persisting the most pernicious contributing factor to the HIV/AIDS pandemic: a cultural bias toward silence. Because the wealthiest can seek treatment quietly and efficiently, or bear their losses without revealing true cause, there is no real need to openly talk about this most difficult thing. And if leaders do not speak up, those dependent on the more visible tiers of treatment (country-based tiers 1 to 4) will not follow.

What can we do to alter these facts? Given what I've said about multiple-tiered medical treatment, I'm afraid that things will only get worse. The wealthy and powerful have the ways and means to keep quiet, to maintain the odd and disturbing silence of cultural practice that surrounds this disease. What is needed is a powerful leader, a champion, man or woman enough to go public about their HIV positive status. They are out there and they must step forward. At the same time, this powerful leader must institute a practice of open and unbiased public testing for all high-ranking government officials. This testing must be accompanied by the near-instant results - we should all bear our fear together. If you are shocked or amused by this demand, then perhaps you should reflect more deeply on the long-term consequences of silence: decimated families, households, communities and societies. Look at the statistics I have provided - they tell a difficult and sad story with no happy ending.