Integrated Regional Information Networks - January 18, 2012
JOHANNESBURG, 18 January 2012 (PlusNews) - One part novella and
two parts textbook, Saturday is for Funerals* pairs the
recollections of Unity Dow, five-times author and Botswana's
first female high-court judge, with the analysis of Harvard
health sciences professor, virologist and chair of the
Botswana-Harvard AIDS Institute, Max Essex.
As Essex notes, Botswana is typically held up as one of the first
African countries to boast early successes in tackling HIV.
Although HIV prevalence remains high, with about one in four
adults living with HIV, it has been particularly hailed for the
early political will shown by leaders, such as former President
Festus Mogae, in addressing HIV.
Under Mogae, Botswana introduced prevention of mother-to-child
HIV transmission (PMTCT) services in 1999 and almost six years
later was able to boast that these services reached as many as 90
percent of all HIV-positive pregnant women. He also introduced
antiretroviral (ARV) treatment by 2002, at a time when former
South African president, Thabo Mbeki, was still questioning the
link between HIV and AIDS, and his health minister, Manto
Tshabalala-Msimang, was describing ARVs as "poisons".
Botswana's national PMTCT programme had been under way for four
years when South Africa finally launched its PMTCT programme in
2003, after a protracted legal battle with the Treatment Action
Campaign, a lobby group.
Changing times, changing lives
Rising HIV prevalence rates in the 1990s meant big changes in
Botswana. By 2000, writes Essex, the World Health Organization
had issued dire warnings: 85 percent of 15-year-olds in the
country would die from AIDS-related illnesses; life expectancy
would drop by 44 years.
But Dow recounts the more insidious and poignant changes, the
ones that crept into people's daily lives and culture as deaths
mounted before ARVs were available.
"If you have not seen someone for a while and you meet their
mother, you are afraid to ask after them. Perhaps they have died
and you have not heard," writes Dow, recounting the words of her
mother. "It was never like this before. You must remember
people's children and be sure to ask how they are. How can you
ask about people who may be dead?"
The title of the book itself points to the way rising
AIDS-related deaths meant funerals became a weekend fixture. So
much so that the cultural practice of midnight grave-digging had
to change to meet growing demand. Young men could now be seen
digging graves in the afternoons as well, Essex notes.
Dow recounts how, as an advocate for women and children, she
became an HIV resource for friends, family, strangers and, as a
high court judge, those in her courthouse. When most still will
not name the virus, her directness in approaching the subject is
appreciated, she writes.
In each chapter, Dow's prose is followed by Essex's medical
review of the issues encapsulated in Dow's vignettes. Untrained
experts will likely benefit from Essex's scientific explanations,
particularly of ARV resistance and side-effects. However, there
are gaps. He fails to distinguish between traditional and medical
male circumcision: some forms of traditional circumcision may not
remove enough of the foreskin to offer protection from HIV
infection. In clinical trials, medical male circumcision has been
shown to reduce a man's likelihood of contracting HIV through
vaginal intercourse by up to 60 percent.
His explanation of clinical trial procedures is a welcome
addition, especially when read against the backdrop of mass media
reports that in southern Africa continue to portray participants
as "guinea pigs". However, some would challenge his assertion
that it is important to encourage HIV vaccine trial participants
to avoid pregnancy not only because potential vaccines have not
been tested for safety in pregnant women but because
"additionally it seems important to strongly discourage pregnancy
for HIV-positive women, whether in trials or not, to prevent the
risk that more HIV-positive infants will be born". Such arguments
have resulted in alleged forced sterilizations of HIV-positive
women in Namibia and South Africa, despite the fact that PMTCT
services are available.
Essex's wording around migration is also likely to spark some
discontent: "Refugees and immigrants from all over southern
Africa see Botswana as the place to be. This obviously increases
tension, as well as demand on programmes with limited resources."
Despite the fact that migration has been a facet of southern
Africa for centuries, contributing to the region's high burdens
of HIV and tuberculosis, migrants continue to face challenges in
securing cross-border healthcare. While the Southern African
Development Community has reviewed the idea of health passports
to address this, there has been little progress. As recently as
August 2011, the Botswana government was reportedly refusing to
treat HIV-positive foreign nationals in its prisons.
In addition, the number of migrants remains difficult to estimate
and research from South Africa and other countries shows that it
is often migrants who wait until it is too late to access care.
Many foreign nationals in Botswana are likely to have come from
countries such as Zimbabwe and Zambia, which have lower HIV
Despite such shortcomings, Saturday is for Funerals manages to
provide a window into how HIV changed one country that largely
seemed to "get it right" when confronting HIV and AIDS while
providing readers with the scientific background to understand
how and why many of the issues faced by Botswana continue to
challenge that country and many others. If nothing else, it is an
addition to the ever-evolving story of HIV in which, as its
authors note, "understanding how people live and love is the key
to understanding how and whether the science breakthroughs will
work, and how to redesign them so they will work better".
* Released as a paperback in 2011