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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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Botswana to Become a Vaccinated Nation: Pandemic Anxiety Over?

30th March 2021

OSCAR MOTSUMI

This is a question that should seriously exercise the mind of every Botswana citizen and every science researcher, every health worker and every political leader political.

The Covid-19 currently defines our lives and poses a direct threat to every aspect and every part of national safety, security and general well-being. This disease has become a normative part of human life throughout the world.

The first part of the struggle against the murderous depredation of this disease was to protect personal life through restrictive health injunctions and protocols; the worst possibly being human isolation and masks that hid our sorrows and lamentations through thin veils. We suffered that humiliation with grace and I believe as a nation we did a great job.

Now the vaccines are here, ushering us into the second phase of this war against the plague; and we are asking ourselves, is this science-driven fight against Covid-19 spell the end of pandemic anxiety? Is the health nightmare coming to an end? What happy lives lie ahead? Is this the time for celebration or caution? As the Non State Actors, we have being struggling with these questions for months.

We have published our thoughts and feelings, and our research reviews and thorough reading of both the local and international impacts of this rampaging viral invasion in local newspapers and social media platforms.

More significantly, we have successfully organised workshops about the impact of the pandemic on society and the economy and the last workshop invited a panel of health experts, professionals, and public administers to advance this social dialogue as part of our commitment to the tripartite engagement we enjoy working with Government of Botswana, Civil Society and Development partners. These workshops are virtual and open to all Batswana, foreign diplomatic missions based in Gaborone, UN agencies located in Gaborone and international academic researchers and professional health experts and specialists.

The mark of Covid-19 on our nation is a painful one, a tragedy shared by the entire human race, but still a contextually painful experience. Our response is fraught with grave difficulties; limited resources, limited time, and the urgency to not only save lives but also avert economic ruin and a bleak future for all who survive. Several vaccines are already in the  market.

Parts of the world are already doing the best they can to trunk the pestilential march of this disease by rolling out mass-vaccinations campaigns that promise to evict this health menace and nightmare from their public lives. Botswana, like much of Africa, is still up in the disreputable, and, unenviable, preventative social melee of masked interactions, metered distances, contactless commerce.

We remain very much at the mercy of a marauding virus that daily runs amuck with earth shattering implications for the economy and human lives. And the battle against both infections and transmissions is proving to be difficult, in terms of finance, institutional capacities and resource mobilization. How are we prepared as government, and as citizens, to embrace the impending mass-vaccinations? What are the chances of us  succeeding at this last-ditch effort to defeat the virus? What are the most pressing obstacles?

Does the work of vaccines spell an end to the pandemic anxieties?

Our panellists addressed the current state of mass-vaccination preparedness at the Botswana national level. What resources are available? What are the financial, institutional and administrative operational challenges (costs and supply chains, delivery, distribution, administering the vaccine on time, surveillance and security of vaccines?) What is being done to overcome them, or what can be done to overcome them? What do public assessments of preparedness tell us at the local community levels? How strong is the political will and direction? How long can we expect the whole exercise to last? At what point should we start seeing tangible results of the mass-vaccination campaign?

They also addressed the challenges of the anticipated emerging Vaccinated Society. How to fight the myths of vaccines and the superstitions about histories of human immunizations? What exactly is being done to grow robust local confidence in the science of vaccinations and the vaccines themselves? More significantly, how to square these campaigns vis-vis personal rights, moral/religious obligations?

What messages are being sent out in these regards and how are Batswana responding? What about issues of justice and equality? Will we get the necessary vaccines to everyone who wants them? What is being done to ensure no deserving person is left behind?

They also addressed issues of health data. To accomplish this mass-vaccination campaign and do everything right we need accurate and complete data. Poor data already makes it very hard to just cope with the disease. What is being done to improve data for the mass-vaccination campaign? How is this data being collected, aggregated and prepared for real life situation/applications throughout Botswana in the coming campaign?

We know in America, for example, general reporting and treatment of health data at the beginning of vaccinations was so poor, so chaotic and so scattered mainstream newspapers like The Atlantic, Washington Post and the New York Times had to step in, working very closely with civil society organizations, to rescue the situation. What data-related issues are still problematic in Botswana?

To be specific, what kind of Covid-19 data is being taken now to ready the whole country for an effective and efficient mass-vaccination program?

Batswana must be made aware that the  end part of vaccination will just mark the beginning of a long journey to health recovery and national redemption; that in many ways Covid-19 vaccination is just another step toward the many efforts in abeyance to fight this health pandemic, the road ahead is still long and painful.

For this purpose, and to highlight the significance of this observation we tasked our panellists with  the arduous imperative of  analysing the impact of mass-vaccination on society and the economy alongside the pressing issues of post-Covid-19 national health surveillance and rehabilitation programs.

Research suggests the aftermath of Covid-19 vaccination is going to be just as difficult and uncertain world as the present reality in many ways, and that caution should prevail over celebration, at least for a long time. The disease itself is projected to linger around for some time after all these mass-vaccination campaigns unless an effort is made to vaccinate everyone to the last reported case, every nation succeeds beyond herd immunity, and cure is found for Covid-19 disease. Many people are going to continue in need of medications, psychological and psychiatric services and therapy.

Is Botswana ready for this long holdout? If not, what path should we take going into the future? The Second concern is , are we going to have a single, trusted national agency charged with the  mandate to set standards for our national health data system, now that we know how real bad pandemics can be, and the value of data in quickly responding to them and mitigating impact? Finally, what is being done to curate a short history of this pandemic? A national museum of health and medicine or a Public Health Institute  in Botswana is overdue.

If we are to create strong sets of data policies and data quality standards for fighting future health pandemics it is critical that they find ideological and moral foundations in the artistic imagery and photography of the present human experience…context is essential to fighting such diseases, and to be prepared we must learn from every tragic health incident.

Our panellists answered most of these questions with distinguished intellectual clarity. We wish Batswana to join us in our second Mass-vaccination workshop.

*Oscar Motsumi: Email:oscar.motsumi@gmail.com

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The women you see in the news matter. Here’s why

9th March 2021
Jane Godia

Jane Godia

Today is International Women’s Day – it’s a moment to think about how much better our news diet could be if inequities were eliminated. In 1995, when the curtains fell in one of the largest meetings that have ever brought women together to discuss women in development, it was noted that women and media remain key to development.

Twenty-six years later, the relevant “Article J” of the Beijing Platform for Action, remains unfulfilled. Its two strategic objectives with regard to Women and Media have not been met. They are
Increase the participation and access of women to expression and decision-making in and through the media and new technologies of communication

Promote a balanced and non-stereotyped portrayal of women in the media.

Today, as we mark International Women’s Day, it’s an indictment on both media owners and civil society that women remain on the periphery of news-making. They cannot claim equal space in either the structures of newsrooms or in the content produced, be that as sources of news or as the subjects of reports. Indeed, the latest figures from WAN-IFRA’s Women in News Programme show just one in five voices in news belong to women*, be they as sources, as the author or as the main character of the news report.

Some progress was evident several years back, with stand-out women being named as chief executive officers, editors in chief, managing editors and executive editors. But these gains appear short lived in most media organisations. Excitement has turned to frustration as one-step forward has been replaced with three steps backwards. In Africa, the problem is acute. The decision-making tables of media organisations remain deprived of women and where there are women, they are surrounded by men.

Few women have followed in the footsteps of Esther Kamweru, the first woman managing editor in Kenya, and indeed sub-Saharan Africa. Today’s standout women editors include Pamela Makotsi-Sittoni (Nation Media Group, Kenya), Barbara Kaija (New Vision, Uganda), Mary Mbewe (Daily Nation, Zambia), Margaret Vuchiri (The Monitor, Uganda), Joyce Shebe (Clouds, Tanzania), Tryphinah Dongwana (Weekend Post, Botswana), Joyce Mhaville (Independent Television -ITV, Tanzania) and Tuma Abdallah (Standard Newspapers,Tanzania). But they remain an exception.

The lack of balance between women and men at the table of decision making has a rollback effect on the content that is produced. A table dominated by men typically makes decisions that benefit men.

So today, International Women’s Day is a grim reminder that things are not rosy in the news business. Achieving gender balance in news and in the structure of media organisations remains a challenge. Unmet, it sees more than half of the population in our countries suffer the consequences of bias, discrimination and sexism.

The business of ignoring the other half of the population can no longer be treated as normal. It’s time that media leaders grasp the challenge, not only because it is the right thing to do, but because it also makes a whole lot of business sense: start covering women, give them space and a voice in news-making and propel them to all levels of decision making within your organisation.

We can no longer afford to imagine that it’s only men who make and sell the news and bring in the shillings to fund the media business. Women too are worthy newsmakers. In all of our societies, there are women holding decision making positions and who are now experts in once male-only domains such as engineers, doctors, scientists and researchers.

They can be deliberately picked out to share their perspectives and expertise and bring balance to the profile of experts quoted on our news pages. Media is the prism through which society sees itself and women are an untapped audience. So, as we celebrate International Women’s Day, let us embrace diversity, which yields better news content and business products, and in so doing eliminate sexism. We know that actions and attitudes that discriminate against people based on their gender is bad for business.

As media, the challenge is ours. We need to consciously embrace and reach the commitments made 26 years ago when the Beijing Platform for Action was signed globally. As the news consuming public, you have a role to play too. Hold your news organization to account and make sure they deliver balanced news that reflects the voices of all of society.

Jane Godia is a gender development and media expert who serves as the Africa Director of Women in News programme.  
WOMEN IN NEWS is WAN-IFRA’s ground-breaking programme to increase women’s leadership and voices in the news. It does so by equipping women journalists and editors with the skills, strategies, and support networks to take on greater leadership positions within their media. www.womeninnews.org

Jane Godia, Director, Africa, Women in News

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Why is the media so afraid to talk about sexual harassment?

9th March 2021

MELANIE WALKER

The eve of International Women’s Day presents an opportunity for us to think about gender equality and the long and often frustrating march toward societies that are truly equal.

As media, we are uniquely placed to drive forward this reflection and discussion. But while focusing on the challenges of gender in society, we owe it to our staff and the communities we serve to also take a hard look at the obstacles within our own organisations.

I’m talking specifically about the scourge of sexual harassment. It’s likely to have happened in your newsroom. It has likely happened to a member of your team. It happens to all genders but is disproportionately directed at women. It happens in every industry, regardless of country, culture or context. This is because sexual harassment is driven by power, not sex. Wherever you have imbalances in power, you have individuals who are at risk of sexual harassment, and those who abuse this power.

I’ve been sexually harassed. The many journalists and editors, friends and family members who I have spoken to over the years on this subject have also been harassed. Yet it is still hard for leaders to recognize that this could be happening within their newsrooms and boardrooms. Why does it continue to be such a taboo?

Counting the cost of sexual harassment

Sexual harassment is, simply put, bad for business. It can harm your corporate reputation. It is a drain on the productivity of staff and managers. Maintaining and building trust in your brand is an absolute imperative for media organisations globally. If and when a case gets out of control or is badly handled – this can directly impact your bottom line.

It is for this reason that WAN-IFRA Women in News has put eliminating sexual harassment as a top priority in our work around gender equality in the media sector. This might seem at odds with the current climate where social interactions are fewer and remote work scenarios are in place in many newsrooms and businesses. But one only needs to tune into the news to know that the abuse of power, manifested as verbal, physical or online harassment, is alive and well.

Preliminary results from an ongoing Women in News research study into the issue of sexual harassment polling hundreds of journalists in Sub-Saharan Africa and Southeast Asia indicate that more than 1 in 3 women media professionals have been physically harassed, and just under 50% have been verbally harassed. Just over 15% of men in African newsrooms reported being physically harassed, and slightly less than 1 in 4 reports being verbally harassed. The numbers for male media professionals in Southeast Asia are slightly higher than a quarter on both forms of harassment.

The first step in confronting sexual harassment is to talk about it. We need to strip away the stigma and discomfort around having open conversations about what sexual harassment is and isn’t. Media managers, it is entirely in your power to create dynamics in your own teams that are free from sexual harassment.

Publishers and CEOs, you set the organisational culture in your media company.

By being vocal in recognising that it happens everywhere, and communicating to your employees that you will not tolerate sexual harassment of any kind, you send a powerful message to your teams, and publicly. With these actions, you will help us overcome the legacy of silence around this topic, and in doing so take an important first step to create media environments that truly embrace equality.

Melanie Walker is Executive Director of Media Development of the World Association of News Publishers (WAN-IFRA). She is a creator of Women in News, WAN-IFRA’s ground-breaking programme to increase women’s leadership and voices in the news. It does so by equipping women journalists and editors with the skills, strategies, and support networks to take on greater leadership positions within their media. www.womeninnews.org

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