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Human behaviour is complex; the case of HIV/AIDS …and other communicable diseases

In the 1980s, the International Union Against Tuberculosis and the World Health Organization developed a system of taking anti-Tuberculosis treatment called “Directly Observed Treatment”. This system, later systematized into what is now called “DOTS” (Directly Observed Treatment- Short Course), transformed the approach to treatment of TB and assured very high cure rates and treatment success rates.


What motivated this approach? The problem was that it was very difficult to get TB patients to take their 18 months treatment to completion. Many patients defaulted, i.e., they either disappeared, took their treatment irregularly, or simply collected the tablets monthly to please health workers but did not actually take the tablets. The result was that very few TB patients were treated to completion and cured.


When I took over the National Tuberculosis Programme in Botswana in 1979 that was exactly the situation. Very few patients were finishing treatment and getting cured, so many patients became chronic or died of TB.  This was despite attempts by Government and its partners to address the situation. By the time I took the programme over, it was run by a WHO Medical Officer and had district TB coordinators from the USA Peace Corps and from the Netherlands.  However, the situation did not improve to a significant degree as patients did not just change their habits.


This problem was prevalent in TB programmes around the world. Solutions had to be found. The first thing achieved was the discovery of new drugs that cut down treatment to six months. Research had been going on for some time to develop new drugs which would be more powerful and would reduce treatment time. It was reckoned that this would improve treatment compliance.

So, by the close of the 1970s new drugs had been developed that would reduce treatment time to six months. However, while shortening treatment did improve compliance significantly and reduced defaulter rates, thus improving cure rates, it was still not enough. Hence the move to “directly observed treatment”,  which meant that the patient had to be supervised by the health worker for every dose taken.

In other words, on a daily basis the patient had to be observed actually taking treatment by the health worker or a designated person. This dramatically improved cure rates in Tuberculosis and many countries that adopted this approach started to make noticeable impact on their TB rates.


Here in Botswana we adopted the Short Course Chemotherapy of 6 months in 1985, the first country in Africa to do so outside those like Tanzania and Malawi that were pilot projects for DOTS under the IUAT and WHO programme. It should be noted that these new drugs were much more expensive than the old drugs, and few African countries could afford them without aid. Botswana went ahead and introduced the new drugs, implementing Short Course Chemotherapy and also adopting directly observed treatment as this was a condition of moving to the new drugs.

This paid dividends. TB notification rates started to decline in the mid-1980s, but unfortunately started to rise steeply in the early 1990s because of the impact of the HIV epidemic. Botswana experienced a three-fold increase in TB notification rates because of HIV; other countries in Southern Africa experienced up to five-fold increases.


The above introduction on TB is meant to illustrate how complex human behaviour is. The world has experienced many major epidemics and pandemics since history started. For example, a third of the population of Europe was decimated by the Plague (Pasteurella pestis) epidemic of the 14th century. Since it was before the discovery of micro-organisms and their role in disease causation, all sorts of groups of people were victimized and blamed as the cause.

Plague is transmitted by fleas from certain species of rats. Europe also experienced epidemics of Cholera in the 19th century that resulted in very high mortality rates. It was during one of these epidemics in London that the role of water in the transmission of Cholera was discovered and demonstrated.

This has since become a classic case study for study of investigative Epidemiology. In 1917-18 there was a major pandemic of influenza that resulted in very high mortality rates around the world. I am quoting these examples to illustrate that the human race has always faced major epidemics or pandemics caused by micro-organisms and many of them were self-limiting because their causation was not even known or understood.

There are always emerging diseases. Luckily, in the last two or so centuries medical knowledge has advanced so much that the causes of these emerging diseases, almost invariably micro-organisms, are always discovered and control measures put in place. In the last half century or so, medical science has advanced more than in all previous history.


Most major epidemics and pandemics in history were caused by acute illnesses. In the modern era what facilitates control of such diseases is i) having a good knowledge of their incubation period, ii) the disease having easily recognizable signs and symptoms, iii) the disease having a high manifestation rate, i.e., infected people showing signs and symptoms so making diagnosis of cases easy and iv) the mode of transmission of the disease being well known.

These factors facilitate control measures based on diagnosis, surveillance and containment, including quarantine when necessary. In the modern era, the discovery of microscopic organisms as causes of disease (19th century) and the discovery of antibiotics were also great milestones in the control of epidemics. The former also led to the development of vaccines for many diseases, while the latter made virtually all bacterial diseases curable. Viral diseases, such as influenza and HIV/AIDS are still largely not curable by antibiotics.


The most challenging pandemic in the modern era has been the HIV/AIDS pandemic. For several reasons its control has not been easy. Firstly, the factors listed above are not operative in HIV/AIDS; i) the incubation period is very long and variable, sometimes being as long as five or more years; ii) the signs and symptoms of HIV related illness are highly variable as it is a syndrome that manifests differently in different individuals because the illness results from suppression of immunity; and iii) many infected people carry the virus and are infectious for many years without having any recognizable signs or symptoms. While the mode of transmission is known, it is a mode that people do not want to talk about because it carries a moral stigma.

This is transmission through sexual intercourse. As a result those infected are not keen to be known because they are afraid that they will be regarded as immoral, sexually permissive or promiscuous. This stigma results in many HIV infected individuals not knowing their status but remaining sexually active and transmitting the virus to their partners.


It is now more than thirty years since AIDS and the virus that causes it-HIV- were discovered and described. In Botswana after the first infected individuals were diagnosed in 1985 the pandemic has now been active for about 30 years. Yet despite the amount of information that has been churned out here and in other countries, new infections continue to occur at a high rate, especially in Africa, and more especially in Southern Africa, which remains the epicentre of the epidemic.


In Public Health we have always been taught that Knowledge should lead to change in Attitude and subsequently to change in Practice (K-A-P). But we have also been taught that things do not always work out that way. HIV/AIDS has clearly demonstrated that people do not necessarily use the knowledge they have gained to change their attitudes and practices for the better. Factors that result in people not using knowledge are many and complex, and being not a behavioural scientist I cannot say much about the subject.


What we have seen in Botswana is that failure of people to change attitudes and practices in relation to HIV/AIDS has resulted in extensive blame game. And as usual the press and others have had a feast laying the blame on Government. I would like to argue here that while the Government response may not have been perfect, especially in the early days when knowledge about the disease was rather sparse anyway, the response has strengthened considerably with time, but the response of the sexually active population has been very far from optimal.


From the very early period of the HIV epidemic in Botswana, the Government, initially led by the Ministry of Health, faithfully followed WHO and other international guidelines in putting its response in place. The very first strategic response was put out in the 1980s and was revised every three to four years as recommended.

The bulk of the strategy related to transmitting information to the public. At a technical level the response to the HIV epidemic was therefore sound in Botswana from the beginning. The political response, and response from the traditional and other leadership, as well as civil society however lacked behind. This obviously did cause some problems in the delay. However, we have to accept that information on the transmission of the virus, information that the individual needed to change his/her behaviour was available from the beginning of the epidemic.


The Health Sector initially ran the HIV response in Botswana, but in line with international trends and recommendations, by the early 1990s the response was made multisectoral as HIV/AIDS was recognized as a development as opposed to a health problem. The National AIDS Council was created and other sectors were drawn into the response.


Botswana and other countries of the extreme Southern tip of the continent (SACU) had the advantage that their epidemic was late, when countries in Central and East Africa had already borne the epidemic for some years. So after the diagnosis of the first sero-positive cases, as we watched the virus spread, we were able to predict what would happen and warn the leadership and the public in general. By the end of the 1980s the Ministry of Health was issuing warnings about the impending large number of cases and deaths. Unfortunately the leadership and the public did not respond in a commensurate manner.

So, when the illness and deaths hit the country from the middle 1990s, it was virtually the ‘we told you so’ phenomenon from the health sector. We had mistakenly thought that the experiences of Central and East Africa would make the people of the country more receptive to the messages and warnings of the Health Sector.  Unfortunately that was not the case. Many seminars and workshops were run for leadership at all levels and for the public without much impact on behavioural change. The media and other routes were also saturated with messages without impact.


Read part two next weekend

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Opinions

Can we cure ourselves from the cancer of corruption?

28th October 2020
DCEC DIRECTOR: Tymon Katholo

Bokani Lisa Motsu

“One of the saddest lessons of history is this: If we’ve been bamboozled long enough, we tend to reject any evidence of the bamboozle. We’re no longer interested in finding out the truth. The bamboozle has captured us. It’s simply too painful to acknowledge, even to ourselves, that we’ve been taken. Once you give a charlatan power over you, you almost never get it back.” Carl Sagan

Corruption is a heavy price to pay. The clean ones pay and suffer at the mercy of people who cannot have enough. They always want to eat and eat so selfishly like a bunch of ugly masked shrews. I hope God forgives me for ridiculing his creatures, but that mammal is so greedy. But corruption is not the new kid on the block, because it has always been everywhere.

This of course begs the question, why that is so? The common answer was and still is – abuse and misuse of power by those in power and weak institutions, disempowered to control the leaders. In 1996, the then President of The World Bank, James D. Wolfensohn named the ‘C-Word’ for the first time during an annual meeting of the Bretton Woods Institutions. A global fight against corruption started. Transparency International began its work. Internal and external audits mushroomed; commissions of inquiry followed and ever convoluted public tender procedures have become a bureaucratic nightmare to the private sector, trying to fight red tape.

The result is sobering corruption today is worse than it was 25 years ago. There is no denying that strong institutions help, but how does it come that in the annual Transparency International Ranking the same group of countries tend to be on the top while another group of countries, many African among them, tend to be on the bottom? Before one jumps to simple and seductive conclusions let us step back a moment.

Wolfensohn called corruption a cancer that destroys economies like a cancer destroys a body. A cancer is, simplified, good cells in a body gone bad, taking control of more and more good cells until the entire body is contaminated and eventually dies. So, let us look at the good cells of society first: they are family ties, clan and tribe affiliation, group cohesion, loyalty, empathy, reciprocity.

Most ordinary people like the reader of these lines or myself would claim to share such values. Once we ordinary people must make decisions, these good cells kick in: why should I hire a Mrs. Unknown, if I can hire my niece whose strengths and weaknesses I know? If I hire the niece, she will owe me and support my objectives.

Why should I purchase office furniture from that unknown company if I know that my friend’s business has good quality stuff? If I buy from him, he will make an extra effort to deliver his best and provide quality after sales service? So, why go through a convoluted tender process with uncertain outcome? In the unlikely case my friend does not perform as expected, I have many informal means to make him deliver, rather than going through a lengthy legal proceeding?

This sounds like common sense and natural and our private lives do work mostly that way and mostly quite well.

The problem is scale. Scale of power, scale of potential gains, scale of temptations, scale of risk. And who among us could throw the first stone were we in positions of power and claim not to succumb to the temptations of scale? Like in a body, cancer cells start growing out of proportion.

So, before we call out for new leaders – experience shows they are rarely better than the old ones – we need to look at ourselves first. But how easy is that? If I were the niece who gets the job through nepotism, why should I be overly critical? If I got a big furniture contract from a friend, why should I spill the beans? What right do I have to assume that, if I were a president or a minister or a corporate chief procurement officer I would not be tempted?

This is where we need to learn. What is useful, quick, efficient, and effective within a family or within a clan or a small community can become counterproductive and costly and destructive at larger corporate or national scale. Our empathy with small scale reciprocity easily permeates into complacency and complicity with large scale corruption and into an acquiescence with weak institutions to control it.

Our institutions can only be as strong as we wish them to be.

I was probably around ten years old and have always been that keen enthusiastic child that also liked to sing the favourite line of, ‘the world will become a better place.’  I would literally stand in front of a mirror and use my mom’s torch as a mic and sing along Michael Jackson’s hit song, ‘We are the world.’

Despite my horrible voice, I still believed in the message.  Few years later, my annoyance towards the world’s corrupt system wonders whether I was just too naïve. Few years later and I am still in doubt so as to whether I should go on blabbing that same old boring line. ‘The world is going to be a better place.’ The question is, when?

The answer is – as always: now.

This is pessimistic if not fatalistic – I challenge Sagan’s outlook with a paraphrased adage of unknown origin: Some people can be bamboozled all of the time, all people can be bamboozled some of the time, but never will all people be bamboozled all of the time.

We, the people are the only ones who can heal society from the cancer of corruption. We need to understand the temptation of scale and address it. We need to stop seeing ourselves just a victim of a disease that sleeps in all of us. We need to give power to the institutions that we have put in place to control corruption: parliaments, separation of power, the press, the ballot box. And sometimes we need to say as a niece – no, I do not want that job as a favour, I want it because I have proven to be better than other contenders.

It is going to be a struggle, because it will mean sacrifices, but sacrifices that we have chosen, not those imposed on us.

Let us start today.

*Bokani Lisa Motsu is a student at University of Botswana

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Opinions

Accounting Officers are out of touch with reality

19th October 2020

Parliament, the second arm of State through its parliamentary committees are one of Botswana’s most powerful mechanisms to ensure that government is held accountable at all times. The Accounting Officers are mostly Permanent Secretaries across government Ministries and Chief Executive Officers, Director Generals, Managing Directors of parastatals, state owned enterprises and Civil Society.

So parliament plays its oversight authority via the legislators sitting on a parliamentary committee and Accounting Officers sitting in the hot chair.  When left with no proper checks and balances, the Executive is prone to abuse the arrangement and so systematic oversight of the executive is usually carried out by parliamentary committees.  They track the work of various government departments and ministries, and conduct scrutiny into important aspects of their policy, direction and administration.

It is not rocket science that effective oversight requires that committees be totally independent and able to set their own agendas and have the power to summon ministers and top civil servants to appear and answer questions. Naturally, Accounting Officers are the highest ranking officials in the government hierarchy apart from cabinet Ministers and as such wield much power and influence in the performance of government.  To illustrate further, government performance is largely owed to the strategic and policy direction of top technocrats in various Ministries.

It is disheartening to point out that the recent parliament committees — as has been the case all over the years — has laid bare the incompetency, inadequacy and ineptitude of people bestowed with great responsibilities in public offices. To say that they are ineffective and inefficient sounds as an understatement. Some appear useless and hopeless when it comes to running the government despite the huge responsibility they possess.

If we were uncertain about the degree at which the Accounting Officers are incompetent, the ongoing parliament committees provide a glaring answer.  It is not an exaggeration to say that ordinary people on the streets have been held ransom by these technocrats who enjoy their air conditioned offices and relish being chauffeured around in luxurious BX SUV’s while the rest of the citizenry continue to suffer. Because of such high life the Accounting Officers seem to have, with time, they have gotten out of touch with the people they are supposed to serve.

An example; when appearing before the recent Public Accounts Committee (PAC), Office of the President Permanent Secretary, Thuso Ramodimoosi, looked reluctant to admit misuse of public funds. Although it is clear funds were misused, he looked unbothered when committee members grilled him over the P80 million Orapa House building that has since morphed into a white elephant for close to 10 successive years. To him, it seems it did not matter much and PAC members were worried for nothing.

On a separate day, another Accounting officer, Director of Public Service Management (DPSM), Naledi Mosalakatane, was not shy to reveal to PAC upon cross-examination that there exist more than 6 000 vacancies in government. Whatever reasons she gave as an excuse, they were not convincing and the committee looked sceptical too. She was faltering and seemed not to have a sense of urgency over the matter no matter how critical it is to the populace.

Botswana’s unemployment rate hoovers around 18 percent in a country where majority of the population is the youth, and the most affected by unemployment. It is still unclear why DPSM could underplay such a critical matter that may threaten the peace and stability of the country.
Accounting Officers clearly appear out of touch with the reality out there – if the PAC examinations are anything to go by.

Ideally the DPSM Director could be dropping the vacancy post digits while sourcing funds and setting timelines for the spaces to be filled as a matter of urgency so that the citizens get employed to feed their families and get out of unemployment and poverty ravaging the country.
The country should thank parliamentary committees such as PAC to expose these abnormalities and the behaviour of our leaders when in public office. How can a full Accounting Officer downplay the magnitude of the landless problem in Botswana and fail to come with direct solutions tailor made to provide Batswana with the land they desperately need?

Land is a life and death matter for some citizens, as we would know.

When Bonolo Khumotaka, the Accounting Officer in the Ministry of Land Management, Water and Sanitation Services, whom as a top official probably with a lucrative pay too appears to be lacking sense of urgency as she is failing on her key mandate of working around the clock to award the citizens with land especially those who need it most like the marginalised.  If government purports they need P94 billion to service land to address the land crisis what is plan B for government? Are we going to accept it the way it is?

Government should wake up from its slumber and intervene to avoid the 30 years unnecessary waiting period in State land and 13 years in Tribal land.  Accounting Officers are custodians of government policy, they should ensure it is effective and serve its purpose. What we have been doing over the years, has proved that it is not effective, and clearly there is a need for change of direction.

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Is it possible to make people part of your business resilience planning after the State of Public Emergency?

12th October 2020

THABO MAJOLA

His Excellency Dr Mokgweetsi EK Masisi, the President of the Republic of Botswana found it appropriate to invoke Section 17 (1) of the Constitution of the Republic of Botswana, using the powers vested in him to declare a State of Public Emergency starting from the 2nd April 2020 at midnight.

The constitutional provision under Section 17 (2b) only provided that such a declaration could be up to a maximum of 21 days. His Excellency further invoked Section 93 (1) to convene an extra- ordinary meeting of Parliament to have the opportunity to consult members of parliament on measures that have been put in place to address the spread and transmission of the virus. At this meeting Members of Parliament passed a resolution on the legal instruments and regulations governing the period of the state of emergency, and extended its duration by six (6) months.

The passing of the State of Emergency is considered as a very crucial step in fighting the near apocalyptic potential of the Novel COVID-19 virus. One of the interesting initiatives that was developed and extended to the business community was a 3-month wage subsidy that came with a condition that no businesses would retrench for the duration of the State of Public Emergency. This has potentially saved many people’s jobs as most companies would have been extremely quick to reduce expenses by downsizing. Self-preservation as some would call it.

Most organisations would have tried to reduce costs by letting go of people, retreated and tried their best to live long enough to fight another day. In my view there is silver lining that we need to look at and consider. The fact that organisations are not allowed to retrench has forced certain companies to look at the people with a long-term view.

Most leaders have probably had to wonder how they are going to ensure that their people are resilient. Do they have team members who innovate and add value to the organisation during these testing times? Do they even have resilient people or are they just waiting for the inevitable end? Can they really train people and make them resilient? How can your team members be part of your recovery plan? What can they do to avoid losing the capabilities they need to operate meaningfully for the duration of the State of Public Emergency and beyond?

The above questions have forced companies to reimagine the future of work. The truth is that no organisation can operate to its full potential without resilient people. In the normal business cycle, new teams come on board; new business streams open, operations or production sites launch or close; new markets develop, and technology is introduced. All of this provides fresh opportunities – and risks.

The best analogy I have seen of people-focused resilience planning reframes employees as your organisation’s immune system, ready and prepared to anticipate risks and ensure they can tackle challenges, fend off illness and bounce back more quickly.  So, how do you supercharge your organizational immune system to become resilient?

COVID-19 has helped many organisations realize they were not as prepared as they believed themselves to be. Now is the time to take stock and reset for the future. All the strategies and plans prior to COVID-19 arriving in Botswana need to be thrown out of the window and you need to develop a new plan today. There is no room for tweaking or reframing. Botswana has been disrupted and we need to accept and embrace the change. What we initially anticipated as a disease that would take a short term is turning out to be something we are going to have to live with for a much longer time. It is going to be a marathon and therefore businesses need to have a plan to complete this marathon.

Start planning. Planning for change can help reduce employee stress, anxiety, and overall fear, boosting the confidence of staff and stakeholders. Think about conducting and then regularly refreshing a strategic business impact analysis, look at your employee engagement scores, dig into your customer metrics and explore the way people work alongside your behaviours and culture. This research will help to identify what you really want to protect, the risks that you need to plan for and what you need to survive during disruption. Don’t forget to ask your team members for their input. In many cases they are closest to critical business areas and already have ideas to make processes and systems more robust.

Revisit your organisational purpose. Purpose, values and principles are powerful tools. By putting your organisation’s purpose and values front and center, you provide clear decision-making guidelines for yourself and your organisation. There are very tough and interesting decisions to make which have to be made fast; so having guiding principles on which the business believes in will help and assist all decision makers with sanity checking the choices that are in front of them. One noticeable characteristic of companies that adapt well during change is that they have a strong sense of identity. Leaders and employees have a shared sense of purpose and a common performance culture; they know what the company stands for beyond shareholder value and how to get things done right.

Revisit your purpose and values. Understand if they have been internalised and are proving useful. If so, find ways to increase their use. If not, adapt them as necessities, to help inspire and guide people while immunizing yourself against future disruption. Design your employee experience. The most resilient, adaptive and high performing companies are made up of people who know each other, like each other, and support each other.

Adaptability requires us to teach other, speak up and discuss problems, and have a collective sense of belonging. Listening to your team members is a powerful and disruptive thing to do. It has the potential to transform the way you manage your organisation. Enlisting employees to help shape employee experience, motivates better performance, increases employee retention and helps you spot issues and risks sooner. More importantly, it gives employees a voice so you can get active and constructive suggestions to make your business more robust by adopting an inclusive approach.

Leaders need to show they care. If you want to build resilience, you must build on a basis of trust. And this means leaders should listen, care, and respond. It’s time to build the entire business model around trust and empathy. Many of the employees will be working under extreme pressure due to the looming question around what will happen when companies have to retrench. As a leader of a company transparency and open communication are the most critical aspects that need to be illustrated.

Take your team member into confidence because if you do have to go through the dreaded excise of retrenchment you have to remember that those people the company retains will judge you based on the process you follow. If you illustrate that the business or organization has no regard for loyalty and commitment, they will never commit to the long-term plans of the organisation which will leave you worse off in the end. Its an absolutely delicate balance but it must all be done in good faith. Hopefully, your organization will avoid this!

This is the best time to revisit your identify and train your people to encourage qualities that build strong, empathetic leadership; self-awareness and control, communication, kindness and psychological safety.  Resilience is the glue that binds functional silos and integrates partners, improves communications, helps you prepare, listen and understand. Most importantly, people-focused resilience helps individuals and teams to think collectively and with empathy – helping you respond and recover faster.

Article written by Thabo Majola, a brand communications expert with a wealth of experience in the field and is Managing Director of Incepta Communications.

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