Sunday, June 11, 2023

The general of the red ribbon brigade

In early July 1998, I was part of a two-man team that interviewed President Festus Mogae about his first 100 days in office. We wanted to know what his top three priorities were. They were ÔÇô he answered ÔÇô job creation, job creation, job creation. Understandably so, he had inherited an economy in which about 34 percent of the employable workforce had no jobs.

We talked about HIV/AIDS, and he made what was becoming the standard refrain of people who worked in Government Enclave at the time; gains made over the years were being undermined by this specter. Should, we asked, the nation expect a more concerted government-led effort to address the disease?

“Yes,” he promised. “Unfortunately, given the nature of AIDS it’s about talking and more talking.”
What he meant was that government could provide all the information and preventive measures, but the decisive blow could only be struck by individuals, with each taking responsibility to protect themselves and those around them. Ultimately, success lay in behaviour change.
In the course of the interview, he recounted the losses the economy was experiencing; high mortality of the educated workforce, absenteeism by the sick, and an over-burdened healthcare system that was failing to cope.
“AIDS is like war,” the new president said. “It kills the ablest.”

It was then that he shared with us that government would “soon” pilot a programme to prevent mother-to-child infection.
“If we can save the babies, that is what we are going to do,” he said.

That interview offers helpful insight into what would become the defining preoccupation of Mogae’s presidency ÔÇô the battle against HIV/AIDS. Very early in this presidency, it was clear that the indecisiveness of the previous administration was over. The new man at the State House was the AIDS activist’s Godsend.

Throughout his 10 years in office, Mogae not only kept his eye on this ball; he did not blink. You could not doubt his single-mindedness, courage, and urgent sense of mission. If ÔÇô indeed ÔÇô AIDS was “like war”, and the country was in a state of combat, he would be the general that would marshal his troops.

The story of how HIV got out of hand and developed into a national catastrophe has been documented. When the first case was recorded in 1985, the reaction was more of curiosity than shock. Who was she? Did she date foreigners?
Well into the 1990s, Radio Botswana could not muster the courage to introduce the word “condom” into Setswana lexis, ostensibly due to cultural sensitivity that prohibited usage of sex expletives in public discourse; thus the nation would be bombarded with messages such as the one that advised that one preventative measure was “dikausu”. If the state broadcaster is its master’s voice, then this vacillation could be traced from the top. Before she became health minister in 2004, Professor Sheila Tlou was a university academic and one of the country’s pioneering AIDS activists. She recalls that in 1990, the country’s AIDS movement asked President Ketumile Masire to address the nation on the gripping problem. The request was rebuffed.

In the middle of an indifferent crowd, there was one individual who seemed to grasp what was going on. It was Mogae ÔÇô at the time, the vice president. Through his patronage, a workshop was organized for Members of Parliament. But it was postponed without explanation ÔÇô and never to be rescheduled. Instead, a different one was held for the MPs’ wives.
I once asked a former mid-level technocrat at the ministry of health why, in the early years, they sent out ambiguous messages. It is wrong, she said, to dump all the blame at government’s doorstep. The messages might not have been explicit, but they were comprehensible.

Thus, when Mogae came into office, he was taking over stewardship of a nation that faced the greatest threat in its history, but seemed without a grand strategy to roll back the threat. In contrast to his predecessor’s reluctance to mention AIDS in public, Mogae would publicly declare that if the trend was not reversed promptly, Botswana faced extinction. In September 1998, he would announce commencement of a pilot project of the programme to prevent HIV transmission from expectant mother to child, making Botswana the first country in the developing world to roll out such a programme.

Such was the heightened sense of urgency that here was a president, a few months into the job, who risked everything and introduced a treatment that most of his peers were ambivalent about. It would be recalled that there had been only one trial ÔÇô in Thailand ÔÇô about the efficacy of AZT and good science is always not to base major decisions on the basis of a single trial.

To explain Mogae’s action-man mode, a theory is advanced that as a development economist and someone who had been closely associated with Botswana’s economic development since 1968 when he joined the civil service as a planning officer, he had a good understanding that if a country had an epidemic at the scale that was evident in the mid-90s, it meant an important segment of the population was infected; and if nothing was done the socio-economic impact would be profound. With the health indices fast deteriorating, it meant a large segment of the productive force was hospitalized facing inevitable early death. Many of those on sickbeds were the nation’s best and brightest stars ÔÇô the ablest, as he chose to call them ÔÇô fresh out of tertiary institutions on government scholarship. When the young and educated are being decimated by a silent epidemic, it slows down economic growth and also impairs a nation’s ability to attract foreign investment. When all these variables were put together, the president’s mind was made up that to sit back and watch the graves filling up would be a costly decision.

When Tlou says, “we were seeing a president who was gung ho,” she speaks for the international HIV/AIDS lobby. She would walk into an international meeting of, say, Society for Women Against AIDS in Africa (SWAAA), and they had nothing but praise for Botswana’s new action-oriented leader. The Botswana chapter of SWAAA seized the moment to partner government in the PMTCT rollout.

Obviously, there were going to be challenges associated with PMTCT. How, for instance, would a mother-in-law in a traditional setting react to a new mother who did not breastfeed? There was the lingering question whether a possibility existed that the children could, in adulthood, develop medical complications traceable to the PMTCT treatment. It is said that one of the things that weighed heavily on the president was that while PMTCT saved children’s lives, it created a social problem: orphans who would be raised mostly by grandparents, relatives, and elder siblings.

In the absence of relief for the HIV-infected mother, PMTCT’s uptake was, not unexpectedly, low. The fear of stigma held a firm grip.

In 2000, a study commissioned by cabinet to investigate the feasibility of providing anti-retroviral (ARV) treatment estimated that 300 000 people in Botswana were HIV-positive, and about 100 000 needed treatment. Once again, Botswana under Mogae would open another frontier ÔÇô as the first African country to roll out free ARV treatment.
Dr Themba Moeti, the former deputy permanent secretary at the Ministry of Health, had not yet reached the top rung of the civil service at the time, but he recalls that this was a difficult decision. It is not too convoluted to detect the source of the complexity. It would be recalled that there was no other country in the developing world setting where this intervention had been done at a national scale, and consequently there was no model to learn from. The drugs were expensive, and they required trained personnel to administer them.

At the time, Batho Molomo, the current head of the National AIDS Coordinating Agency (NACA), was still at the Ministry of Finance and Development Planning. It was by virtue of his post at the ministry that he attended the National AIDS Council, and would even chair its HIV/AIDS Finance Committee. This was the committee that was critical to the decision to provide ARV treatment. He recalls the briefing sessions, in which Mogae came out as a very engaging and analytical man of detail who interrogated every element.

There is a common thread that runs throughout the interviews conducted with various officials (some of whom have requested not to be mentioned) who have interfaced with Mogae on the HIV front. They all say he suffers no fools. When you go to brief him, ensure that you are thoroughly informed. His knowledge of the HIV/AIDS field runs deep, they say, and no detail is too minute for him. He knows which drug comes from which pharmaceutical company, and at what price.
When the possibility of treatment was first broached, Molomo recalls that Mogae wanted evidence that this would work, and he was concerned about sustainability.

“It was a process where you saw the man in action, demanding to be satisfied with evidence…Here was a man who would not shy away from disagreeing with you without putting you down. He would challenge you, and want you to challenge him. Sometimes you would even forget that you had engaged the president. He debated without bringing his office to the fore,” Molomo says.
Concern about sustainability of treatment must be understood at two levels. If, indeed, government were going to adopt universal treatment as an intervention, money would have to come from the national purse. Remember that emergence of the epidemic’s manifestation in the country coincided with Botswana’s graduation into a middle-income country, and donor funding was diverted elsewhere. The other consideration was that ARV treatment is a lifelong engagement.

When Botswana introduced ARV treatment, it was against the urgings of some thinkers in the developed world who were of the view that developing countries had no resources to sustain treatment. In a way, they were right. The drugs were prohibitively priced. But Botswana had the resources, although it would be at the cost of various development projects that would have to be delayed. More importantly, Mogae is credited with the foresight to realise the need for partnerships. Thus, Botswana’s allies would include research institutions, private companies such as Merck, and organisations like the Bill and Melinda Gates Foundation. The organisation that Moeti heads ÔÇô ACHAP ÔÇô is a creation of one such partnership.
It was important to establish partnerships very early in the campaign to help ready the country’s health system for ARV treatment. Doctors, nurses, and pharmacists needed to be trained, and the right infrastructure had to be put in place.

In the process, Botswana’s experience has demonstrated that comprehensive ARV treatment can be effected in a developing country setup, and has provided valuable lessons to international organisations like WHO and UNAIDS. And part of Mogae’s enduring legacy was to contribute to a change in perspective in other countries realizing that treatment is possible.

Bold and unpopular decisions have had to be taken on more than one front. A case in point is introduction of routine HIV testing, in 2004, of people who use public health facilities ÔÇô once again, becoming one of the first countries to do so. Health professionals say that that development has helped many people to know their status, and made it easier for health workers to discuss HIV with “customers”.

According to the latest figures, ARV uptake currently stands at 91 780 with 90 percent adherence rate. In the January ÔÇô December 2007 period, PMTCT uptake stood at 37 939.
Important as treatment is to save lives, perhaps more important is to prevent new infection, and that is the direction that Mogae has indicated that the country needs to go. The second phase of the war has been identified as intensification ÔÇô or scale up ÔÇô of HIV prevention. To that end, Mogae even showed interest in the results of a recent study, which suggested that male circumcision could help prevent infection.

I asked Molomo what would have happened had government, under Mogae, not introduced the measures it did.

“The economy would have collapsed,” he said without hesitation. (Mind you, this comes from a man who was the Government Statistician). “People would have died… Our response between 1985 and late 1990s wasn’t so impressive. We saw erosion in development indicators. You could see death all over. (That’s why) the president said we had to delay development in other facets so that we could prevent the disaster we saw coming.”

As Mogae prepares to leave office, Tlou has a suggestion. He should dedicate his time, not to peacekeeping operations, but should adopt an international profile in the fight against HIV/AIDS.


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