Independence Day

September 30 marks Botswana’s 40th year of independence. Politicians, newspapers, taxi drivers—everyone has been celebrating the advances the country has made over the last 40 years. And there is reason to celebrate, so I thought I’d give you a taste. (Many of these stats are from an article in the September Air Botswana magazine, of all places!)

At independence, in 1966, average per capita income in Botswana was less than US$50, which made it one of the poorest countries in world. Much of this income was actually money that was sent back from South Africa by men who had left to work in the mines. At independence, there was not a single government (that is, public) school or hospital in the country. (Not a bad reason for wanting out of the British colonial system!) There were only 13 kilometers of paved road in the whole country, and fewer than a dozen university graduates. The administrative headquarters of the Bechuanaland Protectorate (as it was called under Britain) were actually located in South Africa, making it the only “country” in the world with its ”capital” outside its borders. The UNDP pre-independence survey predicted a bleak future in every area of development and continued economic dependence for at least the next century.

Today, 40 years later, the average per capita income in Botswana is over US$3000, still a long way from U.S. or European levels, but high enough for Botswana to be considered wealthy in comparison to most African countries (and “middle-income” by some measures). The country has been politically stable since independence with a multi-party democracy. Its relative peace and refusal to involve itself in regional politics (and remember, its neighbors include South Africa and Zimbabwe!) has earned it the moniker “Switzerland of Africa.” There is an extensive government system of schools and hospitals, which despite its problems, offers free or almost-free universal education and health care. One article I read said that Botswana now actually has the most kilometers of paved road per 100,000 residents of any country in the world. Literacy rates are over 90% and Botswana now has 29,000 university graduates. Another article said that Botswana actually had the fastest growth rate in the world for part of the 1980s, with significant growth continuing in the 1990s.

Though it’s tempting to pin this economic and developmental transformation on the discovery of diamonds just a few years after independence, it probably wasn’t the main factor (though today Botswana is one of the largest diamond producers in the world, and the government has generally invested its considerable revenue from the producers back into infrastructure). In fact, the earlier discoveries of copper and nickel, plus some less-sexy but ultimately more important renegotiations of customs tax revenues with South Africa were the more likely early factors. The government made big investments in infrastructure, managed to avoid major corruption, and accumulated substantial foreign exchange reserves.

The economy today has not diversified significantly and is still narrowly focused on mining. Since there are fewer than 2 million people in Botswana, the domestic market is small and can’t really support significant industrial production for local consumption. Soil is poor, drought is a recurrent problem, and transport costs are high. Tourism is a big potential area for expansion but the wetlands and grasslands in the north are ecologically vulnerable and probably can’t support huge numbers of visitors. Government bureaucracy is big and getting bigger, and unemployment is an unsolved problem, as there are now more skilled graduates than available jobs. Many like to blame any current problems (especially rising crime rates) on neighboring Zimbabwe, where unemployment and political instability have led to increasing numbers of refugees in Botswana.

But really, though not everyone wants to acknowledge it, the major challenge facing the Botswana economy is HIV/AIDS, with its huge negative impact on productivity and never-ceasing demands on government resources. There’s no way to talk about poverty, say, or orphans, in Botswana without talking about HIV. Life expectancy has fallen dramatically, to the point where it is only 33.9 years today. Without HIV/AIDS, according to the CDC website, it would be 72.4 years. All of the tar roads and university graduates in the world can’t offset that kind of economic hit (leaving out the obvious and devastating social impact). The government is facing the challenge head-on, particularly in comparison to the long string of debacles in South Africa, but the way is not always clear.

Many younger people living in the cities are returning to their home villages this weekend for the Independence Day celebrations. Their parents who live in these villages are often older than the country itself. Even though challenges—and particularly the health challenges I think about most often—remain, today is definitely a day for celebration. So happy birthday, Botswana. Many 40-year-olds would love to look as good!

Botswana AIDS MAP article

I'm pasting this article in because I think it gives a pretty good overview and shows some of the accomplishments in the fight against HIV/AIDS here (and the strong government commitment to treatment). I was at part of the conference that the article describes. It's long, but written for those who don't know Botswana, so useful, I think!

From
http://www.aidsmap.com/en/news/D9641F21-0EB1-454F-8602-F4BFD931F3E8.asp?type=preview
Botswana mounts one of the most successful national responses to HIV/AIDS — but can it maintain the momentum?
Theo Smart, Thursday, September 28, 2006

Unprecedented political will, adept management and innovative partnerships have so far helped Botswana effectively confront its greatest challenge — HIV and AIDS; and, according to reports from the recent Botswana International HIV Conference (held from September 13-16, 2006 in Gaborone, Botswana), the country is meeting many of the targets it has set for itself fighting the disease, in the areas of HIV testing, the rollout of antiretroviral treatment (ART), the prevention of mother to child transmission (PMTCT), and, according to recent surveillance data, in reducing HIV prevalence.

However, the country still faces serious challenges. “We have made some progress but we are not yet out of the woods,” President Festus Mogae said at the Conference opening in Gaborone. “HIV’s persistence continues to severely compromise the health status of our nation. More than any other factor, it threatens to undermine our past gains and future potential as a developing society.”

For example, HIV prevalence is still quite high, public knowledge about HIV incomplete and sexual attitudes and behaviours have been stubbornly resistant to change. Some programmes, such as the infant formula feeding programme, are not operating as smoothly as everyone would like to think. Furthermore, there are indications that the pace of the rollout could even be slowing as the country is reaching the limits of its existing healthcare capacity.

Botswana backgrounder

Botswana is a sparsely populated southern African country about the size of France or Texas. The country achieved independence from the UK on September 30, 1966 and has been a stable democracy ever since. Most Batswana were pastoralists (many still are), and after years of colonial neglect, the country was undeveloped. However, shortly after independence, rich mineral deposits were discovered in the eastern part of the country that dramatically expanded the domestic economy. Then in the 70’s and 80’s, three of the world’s biggest diamond mines were opened in Botswana.

Contrary to popular belief, this has not made many Batswana wealthy — relatively few Batswana actually work in the diamond mines and much of the profit has been reaped by De Beers. However, the government wisely recycled its share of the diamond revenues into domestic public programmes. Botswana belatedly began to build an infrastructure, including one of the best primary healthcare systems in Africa.

Partly because of the diamond revenue, Botswana is now considered a “middle-income” country but this perception of Botswana’s wealth may be somewhat misleading to anyone who has never been there.

For example, the differences remain startling between the development in the east (as evidenced by the prosperous Gaborone) and the relative lack of infrastructure in many remote villages in the centre or west of the country (where there are few paved roads, little electricity or refrigeration, and less “access” to piped water). In the rural settings, people are still probably better off than in many parts of Africa — they are better nourished, and their small grass, stick or mud homes are well maintained. Villages may even have a communal vehicle to transport goods or people into neighbouring towns an hour or two away, and families are able to send their children away to neighbouring towns for schooling. Even so, most people in the more remote areas areas don’t have much.

The majority of Botswana’s 1.7 million citizens live in the more urbanised eastern third of the nation — at least part of the year. Here many homes have indoor plumbing or at least access to piped water somewhere in the village.

Although these urban centres have more infrastructure, conditions in some of the peri-urban communities surrounding the mining towns, such as Selebi-Pikwe, remain poor and overcrowded.

The Batswana are very mobile. Moving between the rural and urban areas is common and people keep close ties to their family village regardless of where they work. Social laws in Botswana are conservative with anti-sodomy laws and laws that forbid divorce for any reason within the first two years of marriage. The latter law may serve as a disincentive to marry, however, as only 11% of the pregnant women participating in the 2005 sentinel survey were married. Multiple concurrent partnerships (with perhaps a wife in the home village and a steady girlfriend in the town) are common, as is intergenerational sex.

The HIV epidemic in Botswana

It was in this environment that, in the late 80’s and early 90’s, HIV-1 subtype C quietly entered into the population and rapidly took hold before anyone anticipated the scale of the problem.

Early projections of the impact of the HIV upon population were particularly dire. It was estimated that by 2010, out of a total population of 2.4 million people, 1.78 million would be infected with HIV.

Fortunately this prediction was substantially off at least partly because of the interventions that the government has put into place. Even so, by 2003, an estimated 350,000 Batswana were HIV-infected, with over 33,000 deaths from HIV/AIDS-related causes that year.

As of the most recent sentinel surveillance report, 33.4% of women attending antenatal clinics were HIV-positive, and an estimated 17.1% of the general population is HIV-infected. These figures are a bit lower than were reported a couple of years ago, though it may be premature to declare this to be a trend (see below). The estimated number of adults aged 15-49 living with HIV is over 256,000 (158,000 women, 98,000 men) but by definition the figure does not include the cumulative number of children and older adults who are now infected.

“It’s a small population and everybody is precious,” said Professor Sheila Tlou, a professor of nursing and an activist around issues of gender and development who is now the Minister of Health in Botswana. “However, we were threatened by HIV/Aids and became one of the highest prevalences in the world.”

Afraid that HIV/AIDS could lead to the very extinction of his people, President Festus Mogae and his government established HIV/AIDS as the government’s highest priority. The President issued a formal declaration of war on HIV/AIDS, established the National AIDS Council and began to mobilise the first and most comprehensive anti-HIV programme in Africa.

The government has committed substantial resources (beyond the 15% of GDP targets to fight HIV set by African governments in the recent Abuja declaration). It sought assistance from foreign experts, and formed strategic partnerships with such as the Botswana Harvard AIDS programme (which among other things, helped develop the KITSO programme to train healthcare workers), the African Comprehensive HIV Programme (partnering with the Bill and Melinda Gates Foundation and Merck), BOTUSA (a partnership with the US Centres for Disease Control), Baylor Children’s Hospital, and more recently PEPFAR.

In 2001, the government commissioned a baseline consultancy report from McKinsey Global Institute to help determine the need for ART and comprehensive care within the country. At the time, it was estimated that 110,000 persons would need ART in Botswana (including 48,000 males, 55,000 females and 7,000 children). A couple of years later, WHO projected that the country had 84,000 people immediately in need of treatment (using WHO guidelines for treatment eligibility).

Of course, scale-up takes time, and operational managers for MASA (Botswana’s ART programme) are fond of saying that the rollout follows a sigmoid pattern (small numbers of patients at first, but with rapid expansion after a site comes fully on line). They made following projections for patient enrollment into MASA:

December 2006 – 60,000
December 2007 – 80,000
December 2008 – 100,000
December 2009 – 150,000

Some positive results

As of June 2006, Botswana already had 68,440 people on ART, including 56,162 in the public sector, 3778 outsourced to private practitioners (but government funded), and 8500 through privately funded insurance/medical aid schemes. Depending on whose figures are used (WHO’s or McKinsey’s), Botswana has put between 70-85% of its eligible citizens with HIV on antiretroviral therapy (ART) — leading to a reduction in mortality as well as improvement in the quality of life for people living with AIDS. In fact, the country is one of few in Africa to have met WHO 3x5 initiative targets

It was quickly realised that voluntary counselling and testing was a bottleneck to enrolment in MASA. People simply weren’t coming in for testing and were not diagnosed for HIV until their disease was already very advanced — at which point, they were more likely to die or fail on therapy. In response, the country established a programme of routine opt-out testing, which foregoes pre-test counselling but is supposed to give people a choice to say no.

In practice, the programme has not been without problems including complaints of testing without knowledge or informed consent. But since its introduction in January 2004, routine testing has dramatically increased the number of people in Botswana who are now aware of their status — and many in immediate need of treatment has been referred to the MASA programme.

“Our routine HIV testing strategy is now widely acknowledged to have been a success, not respective of the continued reservations of a few critics. Through this initiative, some 300,000 [persons] have been tested,” said President Mogae.

One of the first programmes to get off the ground was PMTCT. Now over 90% of the pregnant HIV-positive women in Botswana and their infants reportedly receive antiretroviral prophylaxis for the prevention of mother-to-child-transmission (PMTCT). At least in one evaluation in Francistown, the programme is also highly effective, reducing MTCT to just 7%. However, it may be premature for the government to make claims that the programme is equally successful nation wide.

As already noted, recent sentinel surveillance data suggest that the HIV prevalence could now be falling in the country.

Not time for ululating, yet

“But it is not yet time for us to start ululating. We are definitely seeing declines, especially among young people but we’ll see how far those declines go,” said Minister Tloe.

Indeed, it is quite possible that infection may simply be delayed in younger women — a significant concern as data from the BAIS II study in 2004 suggests that only 23.9% of the women aged 15-19 and only 30.4% of the women between the ages of 20-24% are aware that having multiple partners puts them at increased risk of infection.

And despite surpassing the 2006 goals for ART, there are also indications that the country could now be reaching the inherent limits of the existing healthcare capacity (both in human resources and material infrastructure) as well as the limits of its hospital based delivery model — thus slowing the pace of the rollout.

MASA started out with four sites in key urban settings across the country: Gaborone, Francistown, Maun and Serowe. From there, MASA expanded to the district level hospitals (there are currently 24 health districts in Botswana). Presently, there are 32 full-fledged ART sites.

According to Dr. Ndwapi Ndwapi, Operations Manager of MASA, after the emergency scale-up, many ART sites are suffering from “cumulative infrastructure overload with well patients. And what we mean by this is that by the time you are treating 150,000 patients, most of those patients are healthy and they are required to come every month to the hospital system in pursuit of care. And to have your healthcare system clogged with 120,000 well people, may not be what the healthcare system was designed to do.”

To relieve congestion at the country’s primary ART sites, the programme has been relying more on district level hospitals and plans to move onto their satellite clinics. Dr. Ndwapi says that, by scaling up at these clinics, there is a potential for an additional 128 free-standing treatment centres by 2010.”

But, according to aidsmap.com sources, many of the district level hospitals have already reached capacity and plans to further decentralise care to the clinic and primary healthcare level have, so far, been thwarted by logistical problems. And even should some of those clinics go online, they won’t be able to handle the same numbers of patients managed at the larger hospitals. In the meantime, some of the hospitals are expanding (with substantial sums being spent on construction) — but it is not clear who will staff them.

It is important to remember that the number of people in immediate need isn’t static — it grows as people with HIV experience disease progression. According to Dr. Boga Fidzani, the Monitoring and Evaluation Advisor for National Aids Coordination Agency, it isn’t clear how many people will be needing treatment in the next couple of years: “There’s an urgent need to update estimates on the number of people in need of treatment. The last estimates were actually done in 2001 and we think it is time to come up with fresh estimates.”

“With an increasing number of HIV infected persons now seeking treatment, the capacity we build in terms of human and material infrastructure remains a priority,” said President Mogae.

To expand beyond these limits, and maintain the progress it has already made, the country may need to re-examine some of its policies and protocols, as well as explore new healthcare delivery strategies.

“We shall need to try fresh approaches to try and sustain initiatives that we have already put in place,” said President Mogae.

Proud Batswana like to say that “they will make a way.” How creatively and expeditiously Botswana deals with these challenges will decide whether the nation’s fight against HIV will, in the end, be a victory; while how open the Batswana are about their successes and failures will determine how much they have to teach others in the region.

Over the next week, aidsmap.com plans on examining some of Botswana’s triumphs and ongoing challenges in a series of articles with material drawn from the World AIDS conference in Toronto, the conference in Gaborone, as well as clinic visits and interviews conducted in Botswana since that meeting.

Baby Shower

I went to a baby shower last night with one of the nurses who is my age. I couldn’t understand most of the group discussion, but even when people are speaking fully in Setswana or Ikalanga, enough English words, phrases, and numbers are scattered through the conversation that it’s often possible to grasp the context of the conversation, if not the exact statements. Last night, a big debate ensued that included the words “35” and “37” as well as “Mr. Right,” and “Mr. Left!” Yup, as I confirmed later, it was that famous discussion of whether you should go ahead and have a baby at 35 (or 37) if you haven’t met Mr. Right (and only Mr. Left!). Seems that if you put a big group of women in their 20s and 30s together anywhere in the world, discussion quickly turns to similar themes!

Anyway, it was all quite funny. All of the presents had to be wrapped in nappies (diapers), we had to bring a bar of soap as the code to get in (as best I could understand!), and people who didn’t follow that or other rules were “punished” by having to get up and dance (as much as possible among the 25 or so women packed into a room that couldn’t have been more than 20x20). The mother-to-be was absolutely covered in pink and blue makeup, which I’m assuming was some sort of party game before we arrived. In her prayer at the end (in English, probably partly for my benefit), she thanked God for giving her friends jobs so they could all buy her presents! Then we all went outside and, of course, had a braai (barbecue) and pap. Our Saturday night music was in direct competition with the evening church singing at the house next door. As soon as it came out that I was from the U.S., a bunch of the women (surprise!) wanted to set me up with their brothers. Aw, shucks, I gotta go back to Gabs next week!

Thank You, Sister: Clinics

Nurses are often called “sisters,” with the head nurse called the “matron.” To my surprise, this terminology even carries over to the male nurses, who are also called sisters, at least in the rural clinics. In the government clinics they wear white uniforms with shoulder bars, and I saw a few still wearing small round white hats pinned to their heads.

All post-high-school tuition is paid for by the government, and even living expenses only need to be paid back 50%. For example, the nurse I was talking to today did her three years of nursing school and only owed 5000 Pula (less than $1000) at the end, plus being required to work in government clinics for a minimum of two years.
The clinics vary widely, though most have an “injection room,” a “dressing room,” and a pharmacy or at least a shelf of generic medications. All have huge lines in the mornings, since patients are seen on a first-come, first-served basis, and nobody seems to wait until afternoon, even though the clinics are technically open.

I enjoyed the range of signs and posters on the walls, where a graphic poster of STD lesions might hang next to the morning devotion schedule, which is itself next to the Cryptococcus meningitis poster, or the staff rules poster. I’ll quote verbatim the staff rules posted at one clinic:

“Avoid late coming or knocking off early.
Avoid coming to work untidy.
Avoid coming to work drunk.
Avoid using abusive language.
Avoid ‘busking’ in the sun especially when patients are around.
Avoid absconding from work.”

Good advice to live by, though I think most of you could use a little more “busking” in the sun (even if the patients are around!).

Air Botswana

It’s Botswana’s national airline--I’ve flown it a few times, including my initial connection from Jo’burg to Gabs. The airline seems to be awfully good at losing luggage--they even lost Dikembe Matumbo’s (sp? NBA player) luggage on that connection. I’m sure he wasn’t happy, but he would have been much less happy if he’d been on the Air Botswana flight I just took to Francistown. It was probably the smallest commercial plane I’ve ever been on (with the possible exception of that flight in Belize last year where they ran out of seats and put me in the copilot’s seat, complete with my own set of controls). I am not a tall person, and I had to duck, a lot, to make it down the aisle. Some of the men were literally bent at the waist! Everyone was either laughing or grumbling, or both. No overhead compartments for luggage, no loudspeakers, no flight attendants, no bathroom, no seat numbers, no clean windows, just the pilot saying “you all know how to use the seatbelts, right? If we need them, there are exits here and here. See you in Francistown” and sitting down in the (completely open to the main cabin) cockpit. I had a nice view out of the front of plane!

The Francistown airport makes the Kalamazoo airport look like JFK—it’s sort of a glorified portacabin with a tin roof and curtained departure area. I do like Air Botswana though: you can arrive for flights 20-25 minutes before scheduled departures; if there’s no attendant, the pilots leave a box of food and a can of orange soda on everyone’s seat; and there’s no need to remove shoes or computers or anything at all for security. Best of all, in a shockingly un-Botswana-like piece of non-bureaucracy, when I wanted to change my flight back (which could only be done in the airport of departure) the woman tried to send me back to the travel agent, but then just nodded, checked the list, and stuck a hand-written sticker on my ticket. No lines, no long explanations, no fees, no forms, no trips across town. I was shocked! Of course, then I pushed my luck and asked whether Air Botswana had any reciprocal frequent-flier programs. I was directed to visit the head office (not, of course, at the airport) before 3pm to fill out an application to “start the process.” I don’t need the miles that badly!

UB (University of Botswana)

I’m auditing two graduate history evening classes at the University of Botswana, one on precolonial southern African historiography, the other an intro to African economic history. I’ve been reading and writing papers on nineteenth-century ordinances related to slavery and labor, debates on the closing of the frontier, growth of state systems, origins/demise of native people, impacts of debt and globalization, with ecological history and medical history sprinkled liberally throughout. (So yes, you know I’m happy!) I’ve never really studied African history formally, so it’s been great to think about some of these issues from a totally different perspective. It keeps me busy and helps fill what can otherwise be pretty empty evenings in Gaborone.

Dreaming of Now Now

Botswana is definitely not a country for the impatient. I’d learned the terms “just now” and “now now” in South Africa, but forgotten them in the emphatically “right now” society of the U.S. (and especially of third year med school) until I got back here. People here rarely use the simple term “now.” Instead, they’ll say, for example, “he’s coming just now.” This means he will arrive in anywhere from 15-20 minutes up to maybe a couple of hours. If we’re likely to see him in, say, the next 15 minutes, they’ll instead say “He’s coming now now.” “Now now” is a beautiful thing. I silently pray for “now now” every time I talk to an administrator of anything.

I think people are simply more used to waiting and “queuing” for everything in Botswana. Daily life is full of waiting and being transferred from one office to another. Making even a single photocopy at the university library, for example, is a 3-step process that involves trips to three buildings--to get the form to apply for a copy card, to pay the cashier an exact amount of money, and to have a different administrator actually issue the card. All of these offices have different and limited hours, which do not include lunch hours, evening hours, or weekend hours. Since it’s hard for me to get to campus between, say, 2 and 3:20 pm on a Thursday, 6 weeks into the semester I’ve only just now gotten a card. I inaugurated my card last week and discovered that only one photocopier in the whole library was working. I was literally the eleventh student standing in line for this copier, but nobody was complaining. 27 minutes (and 6 weeks) later, I got to make my copy.
As a side note, nobody is allowed to bring a bag of any kind into the UB library, and there are no lockers or anywhere else to leave bags, so dozens of people just leave bags and backpacks in piles outside the library (despite the sign prohibiting this “for security reasons”). I’ve been known to pile up my books and papers, stuff my pockets, fold up my totebag and stuff it down my shirt, just to get into the library!

I Have No Idea

I’m outside the city now, and questions I was stumped by today included:

“What do you use donkeys for in the U.S.?”

“So if you were going to buy a cow, like for a ceremony [in the U.S], how much would it cost?” (I might be able to tell you what a pound of beef costs, but…)

Eating

Food is easy here, as long as you’re not a vegetarian--and even that is feasible with a little work. It’s pretty good, fairly cheap (especially locally made dishes), and I’ve never gotten sick. Supermarkets in Gaborone have almost everything that is available in the U.S., though odd things can be hard or impossible to find (e.g. can opener, non-sugar cereal, unsweetened juice, hangers, mac and cheese, root beer, measuring cup, maple syrup, hummus, ricotta—hardly the necessities of life). Drinking tap water is no problem, at least in the cities. For lunch I sometimes buy food from the women who sit at stalls all over the country with big silver pots, selling chicken or pounded goat meat or oxtail or other stews, served with stampe (sort of a white bean/corn mash), or pap/papa (cornmeal), or millet, or rice, plus spinachy sorts of vegetables, or cabbage, or beets or, my favorite, pumpkin. A big plate anywhere, even at the supermarket counter, is only 10 pula (about $1.60), including liberal dousings of hot sauce, a seat at the shared plastic table-and-chairs, and use of the communal water pitcher. More formal local restaurants often have funny English signs and menus (my favorite, in Francistown, says in big letters on the main sign: “If you marry me, I will cook for you.” Makes you wonder, doesn’t it?!) Gabs also has some Western-style restaurants that are pricier but good. McDonalds has not yet invaded the country (though there is a KFC, and plenty of South African chicken chains).

Doctors

Bottom line: there are very few doctors here compared to the U.S., with nurses providing the great majority of care. Whole hospitals might have fewer than five doctors, at least until you reach one of the country’s two major referral hospitals. Each government health district includes as many as 50 clinics and tiny health posts, but each district has only a handful of doctors. These doctors rotate among the clinics every day, with the smaller health posts, for example, only having a doctor visit once a month.

As I mentioned in a previous message, Botswana does not have any medical schools, though the first (affiliated with the University of Botswana) is in the early stages of construction. Therefore, there is no such thing as a Botswana-trained doctor, which can cause language and cultural problems. Most come from other African countries, including DRC (Congo), Zambia, Zimbabwe, Ethiopia, Nigeria, Kenya, and Tanzania. Plus, of course, Cuba. These doctors arrive, generally not speaking Setswana, and sometimes (particularly with those from Cuba) English can be a problem. Just as many doctors probably came to Botswana seeking better pay, it seems that some here now are looking ahead to South Africa, even as those in South Africa are dreaming of Europe or the U.S.