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The current two Pandemics that have affected Botswana: HIV/AIDS and Covid-19 – and the response (Reflections from an observer)

Dr Edward T. Maganu
Introduction

The Human Immunodeficiency Virus (HIV) was first detected in Botswana in 1985. The coronavirus that causes Covid-19 was detected in 2020. Both viruses were new, and it was their global occurrence that led to their classification as pandemics.

They have both been traced to animals, something not surprising as most new viruses are actually cross-overs from animals. A virus crosses species, in this case to humans, and its subsequent behaviour depends on how it adapts to the new species. Many are “dead-ends”, the virus cannot multiply or be transmitted between members of the new species.

In the case of the two which are our subject in this paper, the viruses adapted to the new species (human) and underwent mutations that allowed them to be easily transmitted between humans, hence the rapid spread.

The two viruses, HIV and the Covid-19 virus are very different, hence their mode of spread is different and their mechanisms of disease causation and epidemiology are very different. The approach to their control is of necessity very different. To illustrate their difference, HIV is transmitted mainly by sexual intercourse, Covid-19 virus mainly by the droplet method through the respiratory tract.

HIV causes ill health a long time after infection, which can run from about two years to many years (incubation period); the incubation period of Covid-19 is a few days, estimated at between 10 and 14 days. HIV infection leads to the destruction of the immune system, and when the victim gets ill, it can be from any of a wide variety of diseases caused by “opportunistic infections or even cancers”, hence the name Acquired Human Immunodeficiency Syndrome (AIDS).

Covid-19 on the other hand presents generally as an upper respiratory tract infection (URTI) although there are some presenting differently, especially with lower respiratory infection (lungs affected) in the more severe cases. Another but very important difference is that, while Covid-19 is generally an acute, self-limiting illness, with most patients recovering fully within a few weeks, and in fact many showing no symptoms, HIV/AIDS is a chronic condition; once the patient starts signs and symptoms, usually years after infection, this leads invariably to death from one of the opportunistic infections or diseases.

This last scenario used to be the case in the first decades of HIV/AIDS, but has fortunately changed after the development of drugs that in combination are referred to as Highly Active Anti-Retroviral Therapy (HAART, now known as ART).

HIV/AIDS is now treatable and no longer a death sentence, although treatment lasts for life as the drugs do not eliminate the virus from the body but suppress it. As for Covid-19, there is currently, as is the case generally with viral infections, no effective antibiotic or antiviral drug that kills the virus or eliminates it from the body.

Where does this put us? We are essentially dealing with two diseases or pandemics that are very different from each other. I did my post-graduate studies in Public Health during the last years of smallpox eradication, actually I finished the studies in 1978, the year Smallpox eradication was certified in Botswana.

What used to be emphasized, why the world succeeded in eradicating Smallpox was that it had epidemiological characteristics that supported eradication: it was easy to diagnose, even by lay people; it had a consistent incubation period of about 10 days; it virtually had a 100% manifestation rate (everybody infected showed typical signs and symptoms); there was a vaccine against it that was virtually 100% effective. Unfortunately, there have been few diseases with such favourable characteristics for eradication. Hence the next disease targeted for eradication, Polio, is almost done but still causing some problems.

Response to the HIV/AIDS and Covid-19 pandemics in Botswana

When HIV was detected in Botswana in 1985, the world had been aware of the existence of AIDS for about five years, that is, since the outbreaks among gays in America in 1981. By 1985 the virus had been identified but little was known about it; it was still a subject of intense research. However we knew that it caused AIDS and was no longer just transmitted in gay sex, but that most transmission in Africa was through heterosexual sex, and that sexual transmission was responsible for more than 90% of transmission occurring in Africa.

Some African countries were already experiencing severe HIV/AIDS epidemics, especially in Central and East Africa. In some of them (Uganda is sometimes quoted) people started dying in large numbers before the cause was known, only for people to move to neighbouring villages and infect others there!

The Botswana HIV epidemic, as well as those of SACU countries generally, was later than those of Central and East Africa. The latter had already experienced high disease and mortality rates for some years. In the late 1980s, Botswana was experiencing a big economic boom, and this attracted professionals, technicians and artisans from African countries badly affected by HIV/AIDS, and this really speeded up transmission in the country.

When the first seropositive people were identified in 1985, I was Assistant Director of Health Services responsible for Primary Health Care. So, Disease Control fell in my Department, and I had the responsibility of reporting to my seniors at the Ministry and hence to the country that we now had HIV.

Control measures were started immediately, such as screening all blood donated for transfusion and putting together with the help of WHO, the first short-term control plan. A unit was created which was headed by an appropriate professional. In 1986 I became Director of Health Services and Deputy Permanent Secretary, and in January 1990 I became Permanent Secretary.

In all these positions I was intimately involved in HIV/AIDS control, working intimately with those directly responsible for the unit/programme, and also doing at least one assignment with Global Programme on AIDS (GPA) when it was still with WHO before UNAIDS was created to share the AIDS programme with other UN Agencies. In the same manner, here at home we started pushing for the multisectoral approach to HIV/AIDS control in the early 1990s, that resulted in the formation of the National AIDS Council and eventually NACA.

The Ministry of Health undertook a very intensive public education from early in the HIV epidemic. The Ministry warned the people of Botswana (through and including the political, traditional and community leaders) about what was going to happen, the impending doom of high morbidity and mortality. What was needed was change is sexual behaviour.

Everyone knows that the main message from the Ministry was “ABC” (abstain, be faithful, condomise), which had become a universal message especially in Africa was used by the Ministry. Put in other words, the message aimed at three things; i) delaying sexual debut, ii) avoiding multiple concurrent partners and iii) consistent condom use.

This message never made an impact on the Botswana population, so when the clinical cases started hitting the country after the several years of silent spread (the silent phase of HIV spread), the effect was disaster. We had a nasty surprise in the health system that while the countries in central Africa that had early HIV/AIDS epidemics had their HIV prevalence plateauing at 15% and we thought the same would happen here, in Botswana and Southern Africa prevalence rates went past 30%.

This was due partly to the sexual practices of our people but also to the HIV sub-type that was prevalent in our part of the world. By 1966 Botswana was declared as having the highest prevalence of HIV in the world.

The real heavy load of cases in Botswana started in the mid-1990s, and everybody remembers it; funerals and funerals and funerals. That time ARVs were still under development, and it was only at the end of the 1990s that they became available but very expensive, so most poor and middle income countries could not immediately afford them.

Thanks to India, Thailand and Brazil who broke the patents and manufactured the drugs, their availability to many developing countries would have taken a long time. Here in Botswana, it was due to the initiative of the then President that HAART became available for general use in Government facilities in 2002, with massive aid from PEPFAR and ACHAP (supplied by Merck Foundation and the Bill and Gates Foundation).

Otherwise there was talk of extinction, and the expected population pyramid produced by UNAIDS was frightening. Luckily because of ARV’s that scenario did not occur. The rest of Botswana’s HIV/AIDS trajectory up to now is history. I left Government service on 31st December 1996 after seven years as P.S. and joined WHO.

I had almost joined WHO in 1989 but deferred it when I was appointed PS and did not want to appear unpatriotic and disappoint President Masire and PSP Legwaila with both of whom I had very excellent relations. My initial job with WHO was in Tuberculosis, a disease that had been my passion since I did Public Health and took over its control as head of disease control in 1979.

No matter what post I held in the Ministry thereafter, I participated directly in Tuberculosis control. And as we all know. Tuberculosis became and is still one of the manifestations of HIV globally and in Botswana.

HIV/AIDS was and is a slow epidemic. So, the public did not really perceive it as a threat in Botswana, except perhaps in the late 1990s and early 2000s when it caused very high mortality in the country. The Covid-19 epidemic/pandemic is different. Although it doesn’t kill everybody who gets it like HIV-related disease did, we have seen in highly affected countries that the 2-5% it kills translate to large numbers, because this is an acute infection that spreads very quickly. So, it should be easy for the public to perceive its danger.

The surveillance and containment that has been employed so far in Botswana to control the spread of Covid-19 has been very effective. Those responsible, the Ministry of Health and Wellness and the Task Force deserve to be acknowledged and thanked for a job well done. I am confident that the health care system can also adjust itself and not be disrupted by this new threat.

Since the chances of developing a drug against such a virus seems a bit remote, we are all putting our hope on a vaccine. Many viral diseases have very effective vaccines, so this keeps our hope up. We also need to know if one attack of this disease results in life-long immunity (like measles, mumps, chicken pox etc.) or if one can be attacked more than once, implying that the virus keeps mutating and bringing up new sub-types.

We are still to see if the public will do better than they did with HIV/AIDS and follow the health education. Experience is what usually persuades people to change; that is why many believe the celebrated change in Uganda when people changed and HIV infections dropped was due to the large mortality they had experienced before they even knew what was killing them.

Regarding Covid-19, we are seeing in a number of badly affected countries, people ignoring or resisting social distancing measures and masks, sometimes encouraged by politicians! Here in Botswana we have not yet experienced large losses of lives from Covid-19, so it is still to be seen how the public will really conform to advice, especially on social distancing and other measures like masks and hand washing.

What one sees so far is not very encouraging -in combis, bars etc., and during weekends in homes. In health we talk of KAP (Knowledge, Attitude, Practice). We know that K does not always lead to change in A, and to P. We saw this plainly in HIV/AIDS, what is going to happen in Covid-19?

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The Daring Dozen at Bari

8th December 2020
JEFF---Batswana-smoke-unit

Seventy-seven years ago, on the evening of December 2, 1943, the Germans launched a surprise air raid on allied shipping in the Italian port of Bari, which was then the key supply centre for the British 8th army’s advance in Italy.

The attack was spearheaded by 105 Junkers JU88 bombers under the overall command of the infamous Air Marshal Wolfram von Richthofen (who had initially achieved international notoriety during the Spanish Civil War for his aerial bombardment of Guernica). In a little over an hour the German aircraft succeeded in sinking 28 transport and cargo ships, while further inflicting massive damage to the harbour’s facilities, resulting in the port being effectively put out of action for two months.

Over two thousand ground personnel were killed during the raid, with the release of a secret supply of mustard gas aboard one of the destroyed ships contributing to the death toll, as well as subsequent military and civilian casualties. The extent of the later is a controversy due to the fact that the American and British governments subsequently covered up the presence of the gas for decades.

At least five Batswana were killed and seven critically wounded during the raid, with one of the wounded being miraculously rescued floating unconscious out to sea with a head wound. He had been given up for dead when he returned to his unit fourteen days later. The fatalities and casualties all occurred when the enemy hit an ammunition ship adjacent to where 24 Batswana members of the African Pioneer Corps (APC) 1979 Smoke Company where posted.

Thereafter, the dozen surviving members of the unit distinguished themselves for their efficiency in putting up and maintaining smokescreens in their sector, which was credited with saving additional shipping. For his personal heroism in rallying his men following the initial explosions Company Corporal Chitu Bakombi was awarded the British Empire Medal, while his superior officer, Lieutenant N.F. Moor was later given an M.B.E.

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A Strong Marriage Bond Needs Two

8th December 2020

Remember: bricks and cement are used to build a house, but mutual love, respect and companionship are used to build a HOME. And amongst His signs is this: He creates for you mates out of your own kind, so that you may find contentment (Sukoon) with them, and He engenders love and tenderness between you; in this behold, there are signs (messages) indeed for people who reflect and think (Quran 30:21).

This verse talks about contentment; this implies companionship, of their being together, sharing together, supporting one another and creating a home of peace. This verse also talks about love between them; this love is both physical and emotional. For love to exist it must be built on the foundation of a mutually supportive relationship guided by respect and tenderness. As the Quran says; ‘they are like garments for you, and you are garments for them (Quran 2:187)’. That means spouses should provide each other with comfort, intimacy and protection just as clothing protects, warms and dignifies the body.

In Islam marriage is considered an ‘ibaadah’, (an act of pleasing Allah) because it is about a commitment made to each other, that is built on mutual love, interdependence, integrity, trust, respect, companionship and harmony towards each other. It is about building of a home on an Islamic foundation in which peace and tranquillity reigns wherein your offspring are raised in an atmosphere conducive to a moral and upright upbringing so that when we all stand before Him (Allah) on that Promised Day, He will be pleased with them all.

Most marriages start out with great hopes and rosy dreams; spouses are truly committed to making their marriages work. However, as the pressures of life mount, many marriages change over time and it is quite common for some of them to run into problems and start to flounder as the reality of living with a spouse that does not meet with one’s pre-conceived ‘expectations’. However, with hard work and dedication, couples can keep their marriages strong and enjoyable. How is it done? What does it take to create a long-lasting, satisfying marriage?

Below are some of the points that have been taken from a marriage guidance article I read recently and adapted for this purposes.

POSITIVITY
Spouses should have far more positive than negative interactions. If there is too much negativity — criticizing, demanding, name-calling, holding grudges, etc. — the relationship will suffer. However, if there is never any negativity, it probably means that frustrations and grievances are not getting ‘air time’ and unresolved tension is accumulating inside one or both partners waiting to ‘explode’ one day.

“Let not some men among you laugh at others: it may be that the (latter) are better than the (former): nor let some women laugh at others: it may be that the (latter) are better than the (former): nor defame nor be sarcastic to each other, nor call each other by (offensive) nicknames.” (49:11)

We all have our individual faults though we may not see them nor want to admit to them but we will easily identify them in others. The key is balance between the two extremes and being supportive of one another. To foster positivity in a marriage that help make them stable and happy, being affectionate, truly listening to each other, taking joy in each other’s achievements and being playful are just a few examples of positive interactions.
Prophet Muhammad (PBUH) said: “The believers who show the most perfect faith are those who have the best character and the best of you are those who are best to their wives”

UNDERSTANDING

Another characteristic of happy marriages is empathy; understanding your spouses’ perspective by putting oneself in his or her shoes. By showing that understanding and identifying with your spouse is important for relationship satisfaction. Spouses are more likely to feel good about their marriage and if their partner expresses empathy towards them. Husbands and wives are more content in their relationships when they feel that their partners understand their thoughts and feelings.

Successful married couples grow with each other; it simply isn’t wise to put any person in charge of your happiness. You must be happy with yourself before anyone else can be.  You are responsible for your actions, your attitudes and your happiness. Your spouse just enhances those things in your life. Prophet Muhammad (PBUH) said: “Treat your women well and be kind to them for they are your partners and committed helpers.”

COMMITMENT

Successful marriages involve both spouses’ commitment to the relationship. The married couple should learn the art of compromise and this usually takes years. The largest parts of compromise are openness to the other’s point of view and good communication when differences arise.

When two people are truly dedicated to making their marriage work, despite the unavoidable challenges and obstacles that come, they are much more likely to have a relationship that lasts. Husbands and wives who only focus on themselves and their own desires are not as likely to find joy and satisfaction in their relationships.

ACCEPTANCE

Another basic need in a relationship is each partner wants to feel valued and respected. When people feel that their spouses truly accept them for who they are, they are usually more secure and confident in their relationships. Often, there is conflict in marriage because partners cannot accept the individual preferences of their spouses and try to demand change from one another. When one person tries to force change from another, he or she is usually met with resistance.

However, change is much more likely to occur when spouses respect differences and accept each other unconditionally. Basic acceptance is vital to a happy marriage. Prophet Muhammad (PBUH) said: “It is the generous (in character) who is good to women, and it is the wicked who insults them.”
“Overlook (any human faults) with gracious forgiveness.” (Quran 15:85)

COMPASSION, MUTUAL LOVE AND RESPECT

Other important components of successful marriages are love, compassion and respect for each other. The fact is, as time passes and life becomes increasingly complicated, the marriage is often stressed and suffers as a result. A happy and successful marriage is based on equality. When one or the other dominates strongly, intimacy is replaced by fear of displeasing.

It is all too easy for spouses to lose touch with each other and neglect the love and romance that once came so easily. It is vital that husbands and wives continue to cultivate love and respect for each other throughout their lives. If they do, it is highly likely that their relationships will remain happy and satisfying. Move beyond the fantasy and unrealistic expectations and realize that marriage is about making a conscious choice to love and care for your spouse-even when you do not feel like it.

Seldom can one love someone for whom we have no respect. This also means that we have to learn to overlook and forgive the mistakes of one’s partner. In other words write the good about your partner in stone and the bad in dust, so that when the wind comes it blows away the bad and only the good remains.

Paramount of all, marriage must be based on the teachings of the Noble Qur’an and the teachings and guidance of our Prophet Muhammad (PBUH). To grow spiritually in your marriage requires that you learn to be less selfish and more loving, even during times of conflict. A marriage needs love, support, tolerance, honesty, respect, humility, realistic expectations and a sense of humour to be successful.

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Chronic Joblessness: How to Help Curtail it

30th November 2020
Motswana woman

The past week or two has been a mixed grill of briefs in so far as the national employment picture is concerned. BDC just injected a further P64 million in Kromberg & Schubert, the automotive cable manufacturer and exporter, to help keep it afloat in the face of the COVID-19-engendered global economic apocalypse. The financial lifeline, which follows an earlier P36 million way back in 2017, hopefully guarantees the jobs of 2500, maybe for another year or two.

It was also reported that a bulb manufacturing company, which is two years old and is youth-led, is making waves in Selibe Phikwe. Called Bulb Word, it is the only bulb manufacturing operation in Botswana and employs 60 people. The figure is not insignificant in a town that had 5000 jobs offloaded in one fell swoop when BCL closed shop in 2016 under seemingly contrived circumstances, so that as I write, two or three buyers have submitted bids to acquire and exhume it from its stage-managed grave.

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