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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

The Taiwan Question: China ramps up military exercises to rebuff US provocations

18th August 2022

US House Speaker Nancy Pelosis visit to Taiwan has violated the One-China policy, and caused the escalation of tensions across the Taiwan Strait. Experts and political observers across the spectra agree that Pelosis actions and subsequent pronouncements by US President Joe Biden gave impetus to an already simmering tension in the Taiwan Strait, provoking China to strengthen its legitimate hold on the Taiwan Strait waters, which the US and Taiwan deem as international waters.

Pelosis visit to Chinas Taiwan region has been heavily criticised across the globe, with China arguing that this is a serious violation of the one-China principle and the provisions of the three China-US Joint Communiqus. In response to this reckless move which seriously undermined China’s sovereignty, and interfered in China’s internal affairs, the expectation is for China to give a firm response. Pelosi visit violated the commitments made by the U.S. side, and seriously jeopardized peace and stability across the Taiwan Strait.

To give context to Chinas position over Taiwan region, the history behind gives us perspective. It is also important to note that the history between China and Taiwan is well documented and the US has always recognized it.

The Peoples Republic of China recognises Taiwan as its territory. It has always been the case even before the Nationalist Republic of China government fled to the previously Japanese-ruled Island after losing the civil war on the mainland in 1949. According to literature that threat was contained for decades first with a military alliance between the US and the ROC on Taiwan, and after Washington switched diplomatic recognition to the PRC in 1979 by the US One China policy, which acknowledges Beijings position that Taiwan is part of One China. Effectively, Taiwans administration was transferred to the Republic of China from Japan after the Second World War in 1945, along with the split between the Peoples Republic of China (PRC) and the Republic of China (ROC) as a consequence of the Chinese Civil War. Disregarding this history, as the US is attempting to do, will surely initiate some defence reaction on the side of China to affirm its sovereignty.

However, this history was undermined since Taiwan claimed to democratise in the 1990s and China has grown ever more belligerent. Furthermore, it is well documented that the Biden administration, following the Trump presidency, has made subtle changes in the way it deals with Taipei, such as loosening restrictions on US officials meeting Taiwanese officials this should make China uneasy. And while the White House continues to say it does not support Taiwanese independence, Bidens words and actions are parallel to this pledge because he has warned China that the US would intervene militarily if China attacked Taiwan another statement that has provoked China.

Pelosi, in her private space, would know that her actions amount to provocation of China. This act of aggression by the USA seriously undermines the virtues of sovereignty and territorial integrity which has a huge potential to destabilize not only the Taiwan Strait but the whole of the Asia- Pacific region. The Americans know very well that their provocative behavior is deliberately invoking the spirit of separatism masqueraded as Taiwan independence. The US is misled to think that by supporting separatism of Taiwan from China that would give them an edge over China in a geopolitics. This is what one Chinese diplomat said this week: The critical point is if every country put their One-China policy into practice with sincerity, with no compromise, is going to guarantee the peace and stability across the Taiwan Strait. Therefore, it was in the wake of US House speaker Nancy Pelosis visit to Taiwan, that China, in a natural response revealed plans for unprecedented military exercises near the island, prompting fears of a crisis in the Taiwan Strait and the entire Asia-Pacific region. The world community must promote and foster peace, this may be achieved when international laws are respected. It may also happen when nations respect the sovereignty of another. China may be in a better space because it is well capacitated to stake its territorial integrity, what about a small nation, if this happens to it?

As to why military exercises by Beijing; it is an expected response because China was provoked by the actions of Pelosi. To fortify this position, Chinese President, Xi signed a legal basis for Chinas Peoples Liberation Army to safeguard Chinas national sovereignty, security and development interests. The legal basis will also allow military missions around disaster relief, humanitarian aid and peacekeeping. In addition the legal changes would allow troops to prevent spillover effects of regional instabilities from affecting China, secure vital transport routes for strategic materials like oil, or safeguard Chinas overseas investments, projects and personnel. It then follows that President Xis administration cannot afford to look weak under a US provocation. President Xi must protector Chinas sovereignty and territorial integrity, of which Taiwan is a central part. Beijing is very clear on One-China Policy, and expects all world players to recognize and respect it.

The Peoples Liberation Army has made it clear that it has firepower that covers all of Taiwan, and it can strike wherever it wants. This sentiments have been attributed to Zhang Junshe, a researcher at the PLA Navy Research Institute. Zheng further said, We got really close to Taiwan. We encircled Taiwan. And we demonstrated that we can effectively stop intervention by foreign forces. This is a strong reaction from China to warn the US against provocation and violation of the One-China Policy.

Beijings military exercises will certainly shake Taiwans confidence in the sources of its economic and political survival. The potential for an effective blockade threatens the air and shipping routes that support Taiwans central role in global technology supply chains. Should a humanitarian situation arise in Taiwan, the blame would squarely be on the US.

As Chinas military exercises along the Taiwan Strait progress and grow, it remains that the decision by Nancy Pelosi to visit Chinas Taiwan region gravely undermined peace and stability across the Taiwan Strait, and sent a wrong signal to Taiwan independence separatist forces. This then speaks to international conventions, as the UN Secretary-General Antnio Guterres explicitly stressed that the UN remains committed to the UN General Assembly Resolution 2758. The centerpiece is the one-China principle, namely, there is but one China in the world, the government of the Peoples Republic of China is the sole legal government representing the whole of China, and Taiwan is a part of China. It must be noted that the US and the US-led NATO countries have selectively applied international law, this has been going on unabated. There is a plethora of actions that have collapsed several states after they were attacked under the pretext of the so-called possession of weapons of mass destruction illuminating them as threats – and sometimes even without any valid reason. to blatantly launch military strikes and even unleash wars on sovereign countrie

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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 Botswanas 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, Mogaes 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 theBulela Ditswedispensation, 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 Ditswewas 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 consumers piracy activities, especially in a market the size of Botswanas, 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 dont imagine that their one download will do anything to the production houses 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 musicians 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 Botswanas 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 Africas 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 Botswanas economy are being diverted.

Why cant our local creative industry grow? Why dont 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 Botswanas 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 countrys 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, its 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 economys growth.

Whether you are pirating a Hollywood Blockbuster, illegally streaming a popular Motswana artists 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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