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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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Appendicitis: Recognising the Signs

29th March 2022

Many a times I get clients casually walking into my room and requesting to be checked for “appendix”.  Few questions down the line, it is clear they are unaware of where the appendix is or what to expect when one does have it (appendicitis). Jokingly (or maybe not) I would tell them they would possibly not be having appendicitis and laughing as hard as they are doing. On the other hand, I would be impressed that at least they know and acknowledge that appendicitis is a serious thing that they should be worried about.

So, what is Appendicitis?

Appendicitis is an inflammation of the appendix; a thin, finger-like pouch attached to the large intestine on the lower right side of the abdomen. Often the inflammation can be as a result of blockage either by the faecal matter, a foreign body, infection, trauma or a tumour. Appendicitis is generally acute, with symptoms coming on over the course of a day and becoming severe rapidly. Chronic appendicitis can also occur, though rarely. In chronic cases, symptoms are less severe and can last for days, weeks, or even months. 

Acute appendicitis is a medical emergency that almost always ends up in the operating theatre. Though the appendix is locally referred to as “lela la sukiri”, no one knows its exact role and it definitely does not have anything to do with sugar metabolism. Appendicitis can strike at any age, but it is mostly common from the teen years to the 30s.

Signs to look out for

If you have any of the following symptoms, go and see a Doctor immediately! Timely diagnosis and treatment are vital in acute appendicitis;

Sudden pain that starts around the navel and shifts to the lower right abdomen within hours

The pain becomes constant and increases in severity (or comes back despite painkillers)

The pain worsens on coughing, sneezing, laughing, walking or deep breaths

Loss of appetite

Nausea and vomiting

Fever

Constipation or diarrhoea

Abdominal bloating/fullness

Diagnosis

The doctor often asks questions regarding the symptoms and the patient’s medical history. This will be followed up by a physical examination in which the Doctor presses on the abdomen to check for any tenderness, and the location of the pain. With acute appendicitis, pressing on and letting go of the right lower abdomen usually elicits an excruciatingly unbearable pain. Several tests may be ordered to determine especially the severity of the illness and to rule out other causes of abdominal pain. The tests may conditions include: blood tests, a pregnancy test, urinalysis, abdominal  “How do ultrasound scans work?” ultrasound (scan), CT scan or MRI Scan.

Treatment

The gold standard treatment of acute appendicitis is surgical removal of the appendix known as appendectomy. Luckily, a person can live just fine without an appendix! Surgical options include laparoscopy or open surgery and the type will be decided on by the Surgeon after assessing the patient’s condition. Painkillers and antibiotics are also given intravenously usually before, during and after the surgery.

Complications

Appendicitis can cause serious complications such as;

Appendicular mass/abscessIf the appendix is inflamed or bursts, one may develop a pocket of pus around it known as an abscess. In most cases, the abscess will be treated with antibiotics and drained first by placing a tube through one’s abdominal wall into the abscess. The tube may be left in place for a few hours or days while the infection is clearing up but ultimately one would still have surgery to remove the appendix.

Peritonitis – without treatment, the appendix can rupture/burst. The risk of this rises 48–72 hours after symptoms start. A ruptured appendix spreads the infection throughout the abdomen (peritonitis). This is life threatening and requires immediate surgery to remove the appendix and clean the abdominal cavity.

Death – The complications of appendicitis (and appendectomy) can be life threatening, only if the diagnosis has been missed and no proper treatment has been given on time. This is rare though with the evolved medical care.

If you need further advice or treatment please call 4924730, email  HYPERLINK “mailto:info@themedicscentre.co.bw” info@themedicscentre.co.bw or visit www.themedisccentre.co.bw

Antoinette Boima, MBBS, BMedSci, PgDip HIV/AIDS, Cert Aesth Med is the Managing Director of The Medics Centre in Palapye.

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A degree of common sense

7th February 2022

Here’s a news item from last month you may have missed. In December 2021 the University of Staffordshire announced it would be offered a degree course in pantomime! Yes, that’s right, a degree in popular festive entertainment, the Christmas panto.

We used to have one here, put on by the Capitol Players, though it seems to have fallen away in recent times, but the spectacle is still alive and well in the UK, both in local ad-dram (amateur dramatic ) societies and on the London stage and most of the major cities, these latter productions usually featuring at least one big-draw name from the world of show business with ticket prices commensurate with the star’s salary.

In case you’re unfamiliar with the pantomime format, it consists of a raucous mixture of songs and comedy all based around a well-known fairy or folk tale. Aladdin and His Magic Lamp, Cinderella, Jack & The Beanstalk & Dick Whittington are perennial favourites but any well-known tall tale goes. There is no set script, unlike a play, and storyline is just a peg to hang a coat of contemporary, often bawdy, gags on, in what should be a rollicking production of cross dressing – there has to be at least one pantomime dame, played by a man and always a figure of fun, and a Principal Boy, ostensibly the male lead, yet played by an attractive young woman.

As an art form it can trace its roots back to 16th century Italy and the Commedia Del’Arte which used a mélange of music, dance, acrobatics along with a cast of comic stock characters so it has a long and proud theatrical tradition but you have to wonder, does that really qualify it as a suitable subject for a university? Further, what use might any degree be that can be acquired in a single year? And last but not least, how much standing does any degree have which comes from a jumped-up polytechnic, granted university status along with many of its ilk back in 1992, for reasons best known to the government of the time? Even more worrying are the stated aims of the course.

Staffordshire University claims it is a world first and the masters course is aimed at people working inside as well as outside the industry. Students on the course, due to start in September 2022, will get practical training in the art form as well as research the discipline.

“We want to see how far we can take this,” Associate Professor of Acting and Directing Robert Marsden said. The role of pantomime in the 21st Century was also going to be examined, he said, “particularly post Me Too and Black Lives Matter”. Questions including “how do we address the gender issues, how do we tell the story of Aladdin in 2021, how do we get that balance of male/female roles?” will be asked, Prof Marsden added.

Eek! Sounds like Prof. Marsden wants to rob it of both its history and its comedic aspects – well, good luck with that! Of course that isn’t the only bizarre, obscure and frankly time and money-wasting degree course available. Staying with the performing arts there’s Contemporary Circus and Physical Performance at Bath Spa University. Sounds like fun but why on earth would a circus performer need a university degree?

Or how about a Surf Science and Technology degree at Cornwall College (part of the University of Plymouth). Where the one thing you don’t learn is….how to surf!

Then there is a  degree in Floral Design at University Centre Myerscough. No, I hadn’t heard of it either – turns out it’s a college of further education in Preston, a town that in my experience fits the old joke of ‘I went there once…..It was closed’ to a ‘T’!

Another handy (pun intended) art is that of Hand Embroidery BA (Hons), offered at the University for the Creative Arts. Or you could waste away sorry, while away, your time on a course in Animal Behaviour and Psychology. This degree at the University of Chester teaches you about the way animals think and feel. Cockroaches have personalities according to the subject specs– you couldn’t make it up.

Happily all these educational institutes may have to look to their laurels and try to justify their very existence in the near future. In plans announced this week, universities could face fines of up to £500,000 (P750m), be stripped of their right to take student loans or effectively shut down if they cannot get 60 per cent of students into a professional job under a crackdown on ‘Mickey Mouse’ courses. Further, at least 80 per cent of students should not drop out after the first year, and 75 per cent should graduate.

The rules, published by the Office for Students (OfS), aim to eliminate ‘low-quality’ courses by setting new standards & requiring courses to improve their rating in the TEF, the official universities ratings system. Universities not meeting the new standards will not be able to charge full annual fees of £9,250. Unconventional courses that could fall victim to the new rules could include the University of Sunderland’s BA in Fashion Journalism, where students learn essential’ skills such as catwalk reporting and the history of Chanel.  They have only a 40 per cent chance of entering highly skilled work 15 months after leaving.

At University College Birmingham, BSC Bakery and Patisserie Technology students – who learn how to ‘make artisan bread’ – have a 15 per cent chance of a professional job within 15 months. Universities minister Michelle Donelan welcomed the move, saying ‘When students go to university, they do so in the pursuit of a life-changing education, one which helps pave their path towards a highly skilled career. Any university that fails to match this ambition must be held to account.’

OfS found that at 25 universities, fewer than half of students find professional work within 15 months.  Business and management courses at the University of Bedfordshire (14.8 per cent) were among the least likely to lead to graduate-level jobs.  Asked to comment, the University of Sunderland said it always looked ‘to find ways to improve outcomes’; University College Birmingham said data on graduates and definition of ‘professional work’ was limited. I’ll bet it is! As the saying goes, ’what the eye doesn’t see, the heart doesn’t grieve over’. What a pantomime!

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Why regular health checks are important!

7th February 2022

With the world still reeling from the negative impact of the Coronavirus disease-19 (COVID-19), and the latest Omicron variant (which is responsible for the ongoing global forth wave) on everyone’s lips, we should not forget and neglect other aspects of our health.

While anyone can get infected with corona virus and become seriously ill or die at any age, studies continue to show that people aged 60 years and above, and those with underlying medical conditions like hypertension, heart and lung problems, diabetes, obesity, cancers, or mental illness are at a higher risk of developing serious illness or dying from covid-19.

It is a good habit to visit a doctor regularly, even if you feel healthy. Regular health checks can help identify any early signs of health issues or assess your risk of future illness hence prompting one to take charge and maintain a healthy lifestyle. Heart disease, diabetes, some cancers and other non-communicable diseases (even communicable) can often be picked up in their early stages, when chances for effective treatment are high.

During a health check, your doctor will take a thorough history from you regarding your medical history, your family’s history of disease, your social life and habits, including your diet, physical activity, alcohol use, smoking and drug intake. S/he will examine you including measuring your weight, blood pressure, feeling your body organs and listening to your heart and lungs amongst the rest. Depending on the assessment, your doctor will notify you how often you need to have a health check. If you have a high risk of a particular health condition, your doctor may recommend more frequent health checks from an early age.

Diet – a healthy diet improves one’s general health and wellbeing. It is recommended that we have at least two serves of fruit and five serves of vegetables daily. Physical activity – regular physical activity has significant health benefits on one’s body, mind & soul. It contributes to preventing and managing non-communicable diseases such as cardiovascular diseases, cancers and diabetes, reduce symptoms of depression and anxiety, enhances thinking, learning, and judgment skills and improves overall well-being. According to the world health organisation (WHO), people who are insufficiently active have a 20% to 30% increased risk of death compared to people who are sufficiently active. Aim for 30 minutes to an hour of moderate physical activity at least four days in a week. Examples of moderate physical activity include brisk walking, gentle swimming and social tennis.

Weight – maintaining a healthy weight range helps in preventing long-term complications like cardiovascular disease, diabetes and arthritis. It is also vital for one’s mental wellbeing and keeping up with normal activities of daily living. Ask your doctor to check your body mass index (BMI) and waist circumference annually. If you are at a higher risk, you should have your weight checked more frequently and a stern management plan in place.

Alcohol – as per WHO reports, alcohol consumption contributes to 3 million deaths each year globally as well as to the disabilities and poor health of millions of people. Healthy drinking entails taking no more than two standard drinks per drinking day with at least two alcohol-free days in a week.

Smoking –Nicotine contained in tobacco is highly addictive and tobacco use is a major risk factor for cardiovascular and respiratory diseases, many different types of cancer, and many other debilitating health conditions. Every year, at least a whopping 8 million people succumb from tobacco use worldwide. Tobacco can also be deadly for non-smokers through second-hand smoke exposure. It is not ‘fashionable’ if it is going to cost you and your loved ones lives! If you are currently smoking, talk to your doctor and get help in quitting as soon as possible to reduce the harm.

Blood pressure: Hypertension is a serious medical condition and can increase the risk of heart, brain, kidney and other diseases. It is a major cause of premature death worldwide, with upwards of 1 in 4 men and 1 in 5 women – over a billion people – having the condition. Have your blood pressure checked annually if it is normal, you are aged under 40 and there is no family history of hypertension. You might need to have it checked more frequently if you are over 40, your blood pressure is on the high side, or you have a personal or family history of high blood pressure, stroke or heart attack. Your doctor will be there to guide you.

Dental care – eating a low-sugar diet and cleaning and flossing the teeth regularly can reduce one’s risk of tooth decay, gum disease and tooth loss. Visit a dentist every six months for a dental examination and professional cleaning, or more frequently as per your dentist’s advice.
Blood tests – annual to five-yearly blood tests may be done to further assess or confirm risk of disease. These may include blood sugar levels, cholesterol levels, kidney function, liver function, tumour markers, among other things. They may be done frequently if there is already an existing medical condition.

Cancer screening – various screening techniques can be done to detect different cancers in their early or pre-cancer stages. These include; skin inspections for any suspicious moles/spots, two-yearly mammograms for those at risk of developing breast cancer, Pap smear or the new Cervical Screening Test (CST) every five years, stool tests and colonoscopy (every five years) for those at most risk of bowel cancer, prostate cancer screening for those at risk (over 45 years of age, family history of cancers etc.). Discuss appropriate tests with your doctor.

Vaccinations – You should discuss with your doctor about the necessary routine immunisation, in particular; the Covid-19 vaccines, an annual flu shot, a five-yearly pneumococcal vaccine if you have never had one or you are immunocompromised and any other boosters that you might need.

If you need further advice or treatment please call 4924730, email HYPERLINK “mailto:info@themedicscentre.co.bw” info@themedicscentre.co.bw or visit www.themedisccentre.co.bw

Antoinette Boima, MBBS, BMedSci, PgDip HIV/AIDS, Cert Aesth Med is the Managing Director of The Medics Centre in Palapye.

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