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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

Internal party-democracy under pressure

21st June 2022

British novelist, W. Somerset Maugham once opined: “If a nation values anything more than freedom, it will lose its freedom; and the irony of it is that if it is comfort or money that it values more, it will lose that too.”

The truism in these words cannot be underestimated, especially when contextualizing against the political developments in Botswana. We have become a nation that does not value democracy, yet nothing represent freedom more than democracy. In fact, we desire, and value winning power or clinging to power more than anything else, even if it harms the democratic credentials of our political institutions. This is happening across political parties — ruling and opposition.

As far as democracy is concerned, we are regressing. We are becoming worse-off than we were in the past. If not arrested, Botswana will lose its status as among few democratic nations in the Africa. Ironically, Botswana was the first country in Africa to embrace democracy, and has held elections every five years without fail since independence.

We were once viewed as the shining example of Africa. Those accolades are not worth it any more. Young democracies such as South Africa, with strong institutions, deserves to be exalted. Botswana has lost faith in democracy, and we will pay a price for it. It is a slippery slope to dictatorship, which will bring among other excess, assault on civil liberties and human rights violations.

Former President, Festus Mogae once stated that Botswana’s democracy will only become authentic, when a different party, other than the Botswana Democratic Party (BDP) wins elections, and when the President of such party is not from Serowe.

Although many may not publicly care to admit, Mogae’s assertion is true. BDP has over the years projected itself as a dyed-in-the-wool proponent of democracy, but the moment its stay in power became threatened and uncertain, it started behaving in a manner that is at variance with democratic values.  This has been happening over the years now, and the situation is getting worse by the day.

Recently, the BDP party leadership has been preaching compromise and consensus candidates for 2024 general elections. Essentially, the leadership has lost faith in the Bulela Ditswe dispensation, which has been used to selected party candidates for council and parliament since 2003. The leadership is discouraging democracy because they believe primary elections threaten party unity. It is a strange assertion indeed.

Bulela Ditswe was an enrichment of internal party democracy in the sense that it replaced the previous method of selection of candidates known as Committee of 18, in which a branch committee made of 18 people endorsed the representatives. While it is true that political contest can divide, the ruling party should be investing in political education and strengthening in its primary elections processes. Democracy does not come cheap or easy, but it is valuable.

Any unity that we desire so much at the expense of democracy is not true unity. Like W. Somerset Maugham said, democracy would be lost in the process, and ultimately, even the unity that was desired would eventually be lost too. Any solution that sacrifice democracy would not bring any results in the long run, except misery.

We have seen that also in opposition ranks. The Umbrella for Democratic Change (UDC) recently indicated that its incumbent Members of Parliament (MPs) should not be challenged for their seats. While BDP is sacrificing democracy to stay in power, UDC is sacrificing democracy to win power. It is a scary reality given the fact that both parties – ruling and opposition — have embraced this position and believe democracy is the hindrance to their political ambitions.

These current reality points to one thing; our political parties have lost faith in democracy. They desire power more than, the purpose of power itself. It is also a crisis of leadership across the political divide, where we have seen dissenting views being met with persecution. We have seen perverting of political process endorsed by those in echelons of power to manipulate political outcomes in their favour.

Democracy should not be optional, it should be mandatory. Any leader proposing curtailing of democracy should be viewed with suspicion, and his adventures should be rejected before it is too late. Members of political parties, as subscribers of democracy, should collectively rise to the occasion to save their democracy from self-interest that is becoming prevalent among Botswana political parties.

The so-called compromise candidates, only benefits the leadership because it creates comforts for them. But for members, and for the nation, it is causing damage by reversing the gains that have been made over the years. We should reject leaders who only preach democracy in word, but are hesitant to practice it.

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Opinions

The Big Deal About Piracy

21st June 2022
piracy

Piracy of all kinds continues to have a massive impact on the global creative industry and the economies of the countries where it thrives.

One of the biggest misconceptions around piracy is that an individual consumer’s piracy activities, especially in a market the size of Botswana’s, is only a drop in the pool of potential losses to the different sectors of the economy piracy affects.

When someone sitting in Gaborone, Botswana logs onto an illegal site to download King Richard online, they don’t imagine that their one download will do anything to the production house’s pocket or make a dent in the actors’ net worth. At best, the sensitivity towards this illegal pirating activity likely only exists when contemplating going about pirating a local musician’s music or a short film produced locally.

The ripple effects of piracy at whatever scale reach far beyond what the average consumer could ever imagine. Figures released by software security and media technology company, Irdeto, show that users in five major African territories made approximately 17,4 million total visits to the top 10 identified piracy sites on the internet.

The economic impact of this on the creative industry alone soars to between 40 and 97.1 billion dollars, according a 2022 Dataprot study. In addition, they estimate that “illegally streamed copyrighted content consumes 24% of global bandwidth”.

As Botswana’s creative industry remains relatively slight on the scale of comparison to industries such as Nollywood and Nilewood where the creative industry contributes a huge proportion to West and East Africa’s respective GDPs, that does not imply that piracy activities in Botswana do not have a similar impact on our economy and the ability of our creative industry to grow.

When individuals make decisions to illegally consume content via internet streaming sites they believe they are saving money for themselves in the name of enjoying content they desire to consume. Although this is a personal choice that remains the prerogative of the consumer, looking beyond the fact that streaming on illegal content sites is piracy, the ripple effect of this decision also has an endless trail of impact where funds which could be used to grow the local creative industry through increased consumption, and revenue which would otherwise be fed back into Botswana’s economy are being diverted.

“Why can’t our local creative industry grow?” “Why don’t we see more home-grown films and shows in Botswana?” are questions constantly posed by those who consume television content in Botswana. The answer to this lies largely in the fact that Botswana’s local content needs an audience in order for it to grow. It needs support from government and entities which are in a position to fund and help the industry scale greater heights.

Any organisational body willing to support and grow the local creative industry needs to exist and operate in an economy which can support its mandates. Content piracy is a cycle that can only be alleviated when consumers make wiser decisions around what they consume and how.

This goes beyond eradicating piracy activities in so far as television content is concerned. This extends to the importation and trade in counterfeit goods, resale of goods and services not intended for resale across the border, outside its jurisdiction, and more. All of these activities stunt the growth of an economy and make it nearly impossible for industries and sectors to propel themselves to places where they can positively impact society and reinvest into the country’s economy.

So what can be done to turn the tide here in Botswana in order to see our local production houses gain the momentum required to produce more, license more and expand their horizons? While those who enforce the law continue to work towards minimizing piracy activities, it’s imperative that as consumers we work to make their efforts easier by being mindful of how our individual actions play a role in preventing the success of our local creative networks and our economy’s growth.

Whether you are pirating a Hollywood Blockbuster, illegally streaming a popular Motswana artist’s music, or smuggling in an illegal decoder to view content restricted to South Africa only, your actions have an impact on how we as a nation will make our mark on the global landscape with local creative productions. Thembi Legwaila is Corporate Affairs Manager, MultiChoice Botswana

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Opinions

Our Strength is our Unity

18th March 2022
Craig-Cloud

Putin Chose War.  We Remain United with Ukraine.

U.S. Ambassador Craig L. Cloud

This is a dangerous moment for Europe and for freedom-loving people around the world.  By launching his brutal assault on the people of Ukraine, Vladimir Putin has also committed an assault on the principles that uphold global peace and democracy.  But the people of Ukraine are resilient.

They’ve had a democracy for decades, and their bravery is inspiring the world.  The United States, together with our Allies and partners across the globe, will continue to support the Ukrainian people as they defend their country.  By choosing to pay for a war instead of investing in the needs of Russians, Putin’s invasion of Ukraine will be a strategic failure for the Kremlin and ravage the future of the Russian people.

When the history of this era is written, it will show that Putin’s choice to launch an unprovoked, unjust, and premeditated attack left the West more unified and Russia exponentially weaker.

United in Our Response

This will not end well for Vladimir Putin.  Together, the United States and our Allies and partners are taking action to hold Russia accountable.  As a result of unprecedented global sanctions coordination, the United States, the United Kingdom, the European Union, Japan, and Canada have removed selected Russian banks from the SWIFT messaging system and imposed restrictive measures on the Russian Central Bank.

President Biden announced sweeping financial sanctions and stringent export controls that will damage Russia’s economy, financial system, and access to cutting-edge technology.  After Putin began his invasion, the ruble hit its weakest point in history, and the Russian stock market plunged.

Along with the United Kingdom and European Union, the United States imposed sanctions on the architects of this war, including Putin himself.

By moving in close coordination with a powerful coalition of Allies and partners representing more than half of the global economy, we have magnified the impact of our actions to impose maximum costs on Putin and his regime.  In response to Putin’s war of choice, we will limit Russia’s ability to do business in U.S. dollars.

We will stunt Russia’s ability to finance and grow its military.  We will impair Russia’s ability to compete in the global economy.  And we are prepared to do more.

In addition to economic penalties, this week President Biden authorized an additional $1 billion over the $350 million of security assistance he recently approved, and a $650 million in 2021, to immediately help Ukraine defend itself, bringing America’s total security assistance to Ukraine over the past year to $2 billion.

We also stand ready to defend our NATO Allies.  President Biden has coordinated with Allied governments to position thousands of additional forces in Germany and Poland as part of our commitment to NATO’s collective defense.

He authorized the deployment of ground and air forces already stationed in Europe to NATO’s eastern and southeastern flanks:  Estonia, Latvia, Lithuania, Poland, and Romania.  Our Allies have also added their own forces and capabilities to ensure our collective defense.  There should be no doubt about the readiness of the greatest military Alliance in the history of the world:  NATO is more united than ever.

The United States has also coordinated with major oil-producing and consuming countries to underscore our common interest in securing global energy supplies.  We are working with energy companies to surge their capacity to supply energy to the market, particularly as prices increase.

Putin’s Unprovoked and Premeditated War

This was an attack that Vladimir Putin has planned for a long time.  He methodically moved more than 150,000 troops and military equipment to Ukraine’s border.  He moved blood supplies into position and built field hospitals, demonstrating his intentions all along.

He rejected every good-faith effort by the United States and our Allies and partners to address his fabricated security concerns and to avoid needless conflict and human suffering by engaging in diplomacy and dialogue.

Putin executed his playbook exactly as we had warned he would do.  We saw Russia’s proxies increase their shelling in the Donbas.  We saw the Russian government launch cyber-operations against Ukraine.  We saw staged political theater in Moscow and heard outlandish and baseless claims made about Ukraine in an attempt to justify Russia’s aggression.

Russia continues to justify its military aggression by falsely claiming the need to stop “genocide” in Ukraine – despite there being no evidence that genocide was occurring there.  We saw Russia use these tactics before when they invaded Ukraine in 2014 and Georgia in 2008.

And then, at almost the very same moment the United Nations Security Council was meeting to stand up for Ukraine’s sovereignty and forestall disaster, Putin launched his invasion in violation of international law.  Missiles began to rain down, striking historic cities across Ukraine.  Then came air raids, columns of tanks, and battalions of troops, all riding a renewed wave of disinformation and outright lies.

We have been transparent with the world.  We declassified our intelligence about Russia’s plans so there could be no confusion and no cover up.  Putin is the aggressor.  Putin chose this war.  And now his people will bear the consequences of his decision to invest in war rather than in them.

Transatlantic Unity and Resolve Stronger Than Ever

Putin’s goal of dividing the West has failed.  In the face of one of the most significant challenges to European security and democratic ideals since World War II, the United States and our Allies and partners have joined together in solidarity.  We have united, coordinating intensively to engage as one with Russia and Ukraine, provided assistance to Ukraine, developed a broad response, and reaffirmed our commitment to NATO.

Putin has failed to divide us.  Putin has failed to undermine our shared belief in the fundamental right of sovereign nations to choose their destiny and their allies.  And Putin will fail to erase the proud nation of Ukraine.

The next few days, weeks, and months will be incredibly difficult for the people of Ukraine.  Putin has unleashed great suffering on them.  But the Ukrainian people have known 30 years of independence, and they have repeatedly shown they will not tolerate anyone who tries to take their country backwards.

The world is watching this conflict closely, and if Russian forces commit atrocities, we will explore all international mechanisms that could be used to bring those responsible – whether members of the military or their civilian leadership – to account.

Putin’s aggression against Ukraine will cost Russia profoundly, both economically and strategically.  The Russian people deserve better from their government than the immense cost to their future that this invasion has precipitated.

Liberty, democracy, and human dignity are forces far more powerful than fear and oppression.  In the contest between democracy and autocracy, between sovereignty and subjugation, make no mistake:  Freedom will prevail.

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