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Personal Views Personal views

Africa revisited: a distressing experience

BMJ 2001; 322 doi: (Published 06 January 2001) Cite this as: BMJ 2001;322:59
  1. A W Logie, retired consultant physician
  1. Melrose, and member of Medact

    Seven years ago I was infected with HIV in Zambia. Returning to Britain, I continued working as a physician, with the permission of my local health board and following the guidelines of the government's Expert Advisory Group on AIDS, but keeping my HIV secret. Three years later, I wrote to the BMJ explaining the reasons for ending this self imposed secrecy (BMJ 1996;312:1679).

    More teachers are dying every day than are being replaced

    Recently my wife and I returned to Zambia under the auspices of Christian Aid to visit some of their AIDS outreach and orphan support projects. Some of these projects are based at the hospital in eastern Zambia where I had worked six years ago. A strong longing to go back there to work was tempered by the reluctant realisation that this was wholly impractical, a view reinforced by my later succumbing to an unpleasant gut infection. Coexisting coeliac disease contributes to my susceptibility to such infections and to my being a rapid progressor, but my virus is held in check by highly active antiretroviral treatment, at great cost to the NHS. My guilt over this is compounded by the fact that infected people in Africa have no hope of benefiting from such treatment in the foreseeable future, and I was fearful of encountering resentment and anger from Zambians. This did not occur.

    Seven years ago, in the eastern province, an AIDS outreach programme was under way, with a group of dedicated hospital staff touring the local villages, performing plays, and stimulating discussion in an effort to increase awareness of HIV. Certainly knowledge has improved, but attitudes have not, and much of the stigma and denial persist.

    In Zambia, structural adjustment economies imposed by the International Monetary Fund have led to the scrapping of the national tuberculosis surveillance programme. Seven years ago, a good service operated in the eastern province. Defaulters were pursued and encouraged to return to continue their treatment, with excellent results. This activity has had to be curtailed, through staff cutbacks and an irreparable breakdown of the motorcycles and no money to replace them. Petrol and diesel fuel now costs almost as much as in Britain, adding to funding difficulties. But at least the hospital has been able to ensure a regular supply of antituberculosis drugs, which is not the case in many parts of the country.

    Earlier attempts to introduce DOTS (directly observed treatment, short course) have had to be abandoned. Some local supervision programmes do exist, mainly organised by non-governmental organisations, but surprisingly they operate independently of AIDS programmes. Given that both diseases are rampantly progressing, there is an obvious need for cooperation. The Zambian government, under severe economic pressure, has largely abandoned responsibility for HIV/AIDS and tuberculosis to the non-governmental organisations.

    The United Nations AIDS programme estimates that 33 million people worldwide are living with HIV or AIDS. Of these, 25 million are in sub-Saharan Africa, where 12 million have already died. AIDS in Africa is not merely a medical problem: it is having major socioeconomic effects. Industrial output is falling as a result of the premature death of many skilled workers. The traditional extended family care system has broken down. In Zambia, there are almost half a million AIDS orphans, of a total population of 10 million, and many of these are on the streets, easy prey to exploitation, especially sexual abuse.

    More teachers are dying every day than are being replaced. Education is suffering, and many children, especially girls, are being withdrawn from school because of unaffordable fees. Poverty or abandonment or both is forcing many women to sell sex in return for food for their families. Lack of respect for female sexual rights, dry sex, poor facilities for the affordable treatment of sexually transmitted disease, unpopularity of the male condom, unavailability of male and female condoms, insufficient research, and development of safe, effective, and acceptable vaginal virucides and vaccines: these and many other factors are contributing to the inexorable progression of the pandemic throughout the Third World.

    Is there any hope for Africa? Peter Piot, executive director of UNAIDS, points to recent successes of prevention programmes in Uganda and Senegal, and emphasises that only sustained action by governments at the highest level will prevent regional disasters from developing into a truly global catastrophe. There are signs that the World Bank is at last appreciating the gravity of the situation, but prompt action by the major funding organisations is needed now. Is it too cynical and pessimistic a view that this may not happen until the pandemic starts to hurt the rich North?

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