Blog 16

16/08/09 The dangers of living in sub-saharan Africa.

As we are coming to the end of our year in Africa this blog starts with some of our general thoughts and ideas we have had while living in Zambia.

The sun!

The sun rising over Barotse Plain flooded by the waters of the mighty Zambezi

The one thing that rarely lets us down was also a danger to our aging skin and we rarely completely exposed ourselves to direct sunlight.
At mid-day it takes only minutes for the sun to burn my scalp, the edges of my face and forehead. It meant that I had to wear a cap with a large peak most of the time apart from early morning or late eveningand I never sun bathed.

In Africa umbrellas are for protection against the sun not the rain

This also meant that I only rarely needed to add total block to my nose and neck. Judy was a little less frightened and on occasion sun bathed in the back of our garden or on one of our trips.

I also seemed to knock my bald patch on low ceilings or trees, which meant that although it became pretty tough it constantly peeled. The worst injuries were on the Intercape bus to the desert. We had a TV immediately over our seats, which I constantly forgot to duck beneath!

We may have been a little more sensitive to the sun because of the anti-malarial doxycycline we took, which can make your skin, light sensitive.


HIV/AIDS

This is of course related to the risks arising from our professional activities!

I was quite concerned about the risk of working closely with infected patients even though I knew these fears were completely irrational.

The patients waiting to be seen in a narrow corridor down which we had to squeeze to get to our consulting rooms.






The reception desk where all the patients details were recorded with no privacy

The queue outside

A young very bright school girl being treated for HIV who we visited at her home with two home carers sitting on either side also with HIV, Stone on the right. Stone's second wife has HIV and is a receptionist at the clinic shown in the photo above. The girls mother also has HIV but has not yet needed ARVs five years after diagnosis. Her father died when she was 5yrs old. She wants to go to university to do medicine and although she is clever enough her family probably won't be able to afford it.

Fortunately this feeling rapidly disappeared, to be replaced with one of empathy and of wanting to make patients know I sympathized and understood their situation. This comes with realizing that the many patients with HIV/AIDS become infected out of ignorance or through no fault of their own and in coming to respect the way they accept their situation with great grace.

The 'face' of AIDS; Herpes Simplex ( a cold sore) in a 20 year old boy

The feet of AIDS; a fungal skin infection in a young man was the way his HIV/AIDS presented.

There is of course also the potential risk for surgeons from needle stick injuries. However, although surgeons are known to frequently suffer needle injuries in spite of all precautions, the fact is that it is very rare for surgeons to get infected with HIV in this way. Surgeons are at much greater risk of getting hepatitis and several surgeons are known to have died from this after a needle stick injury.

So why not from HIV? There may be several reasons but probably because HIV is less infective than hepatitis. It may also be that any ‘prick’ through a rubber glove will tend to wipe the needle clean of blood and serum. Thirdly it is known that a prick from a hollow needle is more of a risk for obvious reasons and needle stick injuries in surgeons are generally with solid needles used for suturing. Whatever the reasons most experienced surgeons in Africa have a very relaxed attitude to the risk of infection and do not take any special precautions, apart from techniques to always handle the needle with instruments. If they do prick their fingers they rarely check the status of the patient and even if they know the patient is reactive (positive!) they do not use PEP (post-exposure prophylaxis).

This relaxed approach could be restricted to Monze although I know of other surgeons from other hospitals that have the same approach.

Road Traffic Accidents

Although HIV/AIDS gets all the publicity, trauma and particularly road traffic accidents are probably an equal cause of injuries and mortality in Zambia.

I'm not sure whether this is a good or bad thing!

Most roads have only two tracks, are narrow and are full of potholes, whereas many lorries and buses are very wide and high and travel either too fast or too slow! Both vehicles and roads are poorly maintained.
Accidents may be caused by traffic avoiding the potholes and overturning on the steep banks that line all roads, or from tire damage and burst tires.

Many drivers have little skill, are young and will take risks. Vehicles are stolen and driven by drunk drivers, especially at night. All roads are poorly lit (mostly not lit at all, even in towns), cycles never have lights and even large lorries may not have them, or even more dangerously have a light on only one side. I have twice nearly been knocked down by a cycle when walking down the edge of a dark road without a torch. The cyclist was silently within a few feet before I had any sight of him and had passed before I could have take any avoiding action.

Zambians are carried packed like sardines into the back of open trucks.

When they overturn it is like a major railway crash with multiple deaths of mostly male patients the surviving ones filling a ward both the beds and on mattresses covering the floor. After a crash the driver, if able runs away sometimes never to be seen again. The walking wounded often turn up in Filter Clinic, desperate to have a medical form signed by a doctor to give to the police. This is in order to have all injuries documented to subsequently claims for damages. In a country with such poor people it is difficult to imagine where this money will come from – certainly not from the government.

Every time we travel on the road we take all precautions but I’m always grateful when we arrive home in one piece and will be glad to get back to British roads.

Malaria

When we arrived in Zambia we were frequently advised about how to avoid malaria and it seemed a common topic of conversation for new people in Africa. We were
rapidly told who has had it (most people) and it was not surprising that we quickly adopted a ritual to keep it at bay. So far Judy and I have not had it and only 5 weeks to go and 4 weeks travelling. We never did get it!

We have come to think that the risk has been exaggerated as diagnosis is often based on a hunch or observation of a fever in someone who feels unwell with a headache, even in doctors. The patient then starts treatment with no possibility of confirming the diagnosis. Fast, easy and accurate tests do exist but they are expensive and thus not widely available. In fact, there are real problems regarding resistance to some of the drugs because of this approach. There has just been a fascinating article in the BMJ highlighting this and many other problems including the accurate diagnosis of the disease. For every billion dollars spent on antimalarial drugs, around $500m to $960m will be spent on treatment for people who do not have malaria.

Nevertheless we rigorously take our daily 100mgms of doxycycline which I’m sure has made my scalp more susceptible to the sun, we cover up as the night approaches, we spray ourselves and we always sleep under mosquito nets.

Home





Tongabezi

When we first arrived we regularly heard the buzz of mosquitoes and killed 4-5 each evening in the sitting and dining room and in the morning in the bathroom. Over half the kill would leave a red flash of blood on the wall showing that they had bitten someone, probably ourselves. However as our cover up and spraying improved the 'blood flash' count dropped and over the last 2-3 months have not heard or killed a single mosquito. Tom Lavender suggested there was no need for prophylaxis during the cold season and it seems to be correct.

The water and risk of gut infection

In an early blog we described how quickly we established the rituals for avoiding gut infection from water and contaminated food and how this becomes just a part of life.

Our chrome plated water filter provided by VSO. The water is first boiled in the electrical kettle and after cooling poured into the top container to drain through two large cylindrical porous ceramic filters cleaned 2-3x per year and occasionally need replacing.

We have also been great hand washers and so far only MRT has had one attack of diarrhoea without nausea or pain, lasting a week and not stopping him from working. This occurred after a meal in the best restaurant in Mongu! We continue to boil and filter all water when we have it, wash all fruit and salads in tap water and then rinse in the processed liquid and then dried!

We brush our teeth in bottled water from the boiled and filtered water and mostly only eat cooked food in restaurants.


The bites, snakes, spiders, hippos, crocodiles and rabid dogs.

Although we have seen several examples of these bites in the hospital, particularly snake bites,

with devastating consequences and lost limbs, the risk to ourselves is pretty small. We avoid walking in long grass, stamping heavily as we go to scare them (they have no ears so shouting doesn’t work) as snakes are quite timid unless threatened. We have only seen one or two in non-threatening situations. The hippo and crocodile bites

This young man was caught by a crocodile when going fishing with his brother early one morning. When the croc didn't let go after a beating on the head with an oar he remembered his father had told him to push the oar down the croc's throat and it worked. But not before breaking his radius, ulnar and humerus bones probably by the croc trying to shake him free from the boat.










Xrays of his upper and forearms showing the fractures

heal very well. However we are not sure what makes the crocs and hippos let go of the patients who are subsequently admitted to hospital. We obviously don’t see the patients they don’t let go!

Burglary and Theft

We were told that Zambia was a safe place but all houses have barred windows and doors with padlocks and bolts.

Several friends have had things stolen or their houses broken into. Just before we arrived a farmer was shot and I have treated 3 other patients who have been shot or stabbed. Most of these have been domestic fights or drunken brawls or both. The last one was a man who was beaten up by a friend whom he caught in his own bed with his wife!

We have also adopted rituals to keep my camera and our computers safe in the house by carefully locking them in a wardrobe which has a metal frame with a Yale lock. So far we have not had any problems although small items like books have disappeared from the hospital. We will keep up the vigil until we come home.

Electricity cuts

These continue and often seem to coincide with cooking and when it’s dark! We thought it was more evidence of Zambian laissez fare but we met a Frenchman at Kariba last weekend and he said the reason we avoid them in Europe is because of the circular links locally, regionally, nationally and internationally. If a local system fails it can tap into increasingly distant circuits; whereas in Zambia there are only radial links, and if one system fails the voltage falls across a very large area with consequent power cuts for the whole country. Apparently in Europe we would be unaware of any problem as the links are so good.

A recent prolonged power cut was because weed was swept into just one of the turbines at Kafue Gorge. All the generators had to be closed down and even though there are others in different areas they weren’t sufficient to maintain the system, and virtually the whole country was without electricity for 3 days. When the electricity is off so the water pressure falls and we were also without hot water for 3 days and had boil it on our gas burner. In fact questions were asked in the Zambian parliament about this incident. There is a minister responsible for electricity, although it is not nationalized. He was accused of severe negligence as in fact he must have been aware of this major weed problem (as indeed it was generally known) He was told in no uncertain terms that the weed could not have grown overnight!

When the electricity is off we have to rely on torches even more to get around at night and during the wet weather these weren’t sufficient to keep us out of the very large and hidden black puddles. It is always a great relief when light is restored and we can blow out all the candles and switch off our solar charged lamp.

TB

This more a theoretical worry as it is almost exclusively a problem for HIV/AIDS patients. It is nevertheless difficult to avoid the ‘coughs and sneezes which spread diseases’ in the overcrowded clinics

and wonder how much of the fetid air it is safe to inhale.

A chest Xray showing pulmonary tuberculosis

We will probably get a chest xray a month or two after getting home and hope it isn't like the one above! The real problem though is the fact we may catch a resistant strain, the result of partial treatments. We have seen many patients on treatment especially in the HIV/AIDS clinics although the diagnosis is often made clinically on the basis of an xray and the clinical history without bacteriology.

Lightning

Our worst experience of this was described in a previous blog. We really thought the house would be hit and we would go up in a puff of smoke! The lightening was continuous, the thunder deep and booming and the rain came in bucket loads creating instant rivers. It all lasted several hours.

Needing emergency medical attention or operation

We occasionally wonder what we would do if we became seriously ill or needed surgery. I really don’t like thinking about it. However this is a little silly as it is perfectly feasible to get somewhere to see a trusted specialist fairly quickly if the need arises (South Africa sounds good to us), and white Zambians cope very well with this situation.

Conclusion

In the western world the basic risks of living are small and we do not realize what a luxury that is. The roads are well lit and free of potholes, the water is clean, it is too cold for mosquitoes, TB is almost extinct, HIV/AIDS is rare and very low risk to surgeons. The greatest risks from animals are cat scratches and non-rabid dog bites!
However taking action to reduce these risks in Africa quickly becomes part of the routine of life, is mainly of nuisance value and in fact quickly requires little effort and we avoided the risks of coughs and colds of English life with grandchildren!
Electricity cuts and loss of water are much more a threat to the quality of our lives in Africa forcing us to have fewer baths, to eat by candlelight and to eat out more?

Antics of the Ants!

This has been a major nuisance but also interesting to study. It clearly is a yearly event with ant time starting in May and continuing relentlessly at least until August. It must stop before October, as we don’t remember any problem when we arrived. They come out of every nook and cranny mainly in the kitchen, less so in the bathroom and dining room and almost never in the bedrooms. This is probably because they are more likely to find food in the kitchen. Many come in through the back door from the garden. They send out scouts and once food is found they rapidly develop a route usually along the base of a wall, up the corner of a table leg, along the edge of tiles or along grouting lines. They start as a single line going in both directions building up to multiple lines predominantly going one way. If they remain on the floor they disperse a little but if they are on a shelf or table they tend to remain in a trail. If I follow the trail backwards, and it isn’t always clear to see what is backwards, it always leads to a single point source. The remarkable thing is that if you give one squirt of ‘Doom’ super multi-insect DEADLY KILLING ACTION at the point of entry it only kills a few ants but the whole process is switched off.

The morning after writing this I discovered a humungous invasion on the kitchen table from a point above the skirting board in a line to a socket,

along the electric cable to the Russell Hobbs electric kettle which is free standing on a base from which it gets its power.

Although the ants were into every nook and cranny of the kettle they were clearly aiming for the flat base from which they emerged in there hundreds if not thousands when I shook it. It suddenly occurred to me that these invasions may represent the same phenomenon as swarming bees. The ants may be looking for a new home close to food. The base of the Russell Hobbs must be like a 5 star hotel with warmth, darkness, security and a short run to nourishment. It took 5-10 mins to shake all the ants out of the base!

My hypothesis is that after a very short spray of DOOM at the point of entry into the kitchen they sense danger and most find another new way back to their nest. Whatever the reason for their complete disappearance they or another clone come again from a different site. Each battle leaves a dusting of ants and after a couple of days it is possible to sweep up a considerable pile of ants together with fine sand they seem to leave just outside the entry/exit point.

One day the ants completely disappeared from the kitchen and we thought antics were over for the season. However we then learnt that Bridget our cleaning girl had used Doom to spray all the cracks in the kitchen! Over the next 2-3 days they started to come out in places they had never been before like the sitting room and up through the floor in the bath room. I think the house was built on an ant hill!

The ants are a mixture of sizes from very small almost invisible varieties to the usual sized English strains which can give quite a nip if the get trapped under your clothes.

A final thought is that these antics were developed long before there were houses! However they seemed to have adapted well in this new environment, which seems to provide all their needs. They must believe they have found the ultimate destination for ants in the base of a Russell Hobbs electric kettle the Jerusalem or Salt Lake City for ants!

It will be interesting to read and confirm the truth about the antics of ants. I could of course be wrong!

Judy gets upset with them but I find it just another fascinating aspect of living in Africa.

Yes, it is amazing as to how pervasive they are. I often prepare or cook with them running about my feet. I then start feeling tickles everywhere - real or imagined – and can pick them off from my face. How do they get there without me being aware? They only give a nip if trapped – under a sandal strap or watch strap.

The Plague of Frogs

We had heard the frogs outside at night when the wet season started. Just one sitting happily in a warm puddle made a loud resonating croak that continued until a torch was shone in its face. I didn’t really think of it as a problem until small ones started coming into our home, mainly at night. They were, anything from 1 to 4 cms long, slimy and anaemic looking. I didn’t particularly like them sitting on the edge of the bath watching me wash. On two occasions I didn’t notice them in the loo until I stood up to flush. MRT used pick them up with loo paper, squash them, and flush them away. It sometimes took more than one flush and they would continue swimming even though they were virtually headless. I always had a phobia that I would step on one at night – so all the lights went on if I had to get out of bed.
Occasionally they were larger and MRT was summoned to rescue the girls next door from a monster one. No, they never tried kissing one! At the end of the rainy season they all disappeared. Where to? I haven’t a clue.

The Benefits and Dangers of First World Aid

We came to Africa unsure about the benefit of world aid to developing counties and the motivation for giving it! Unfortunately our doubts were not assuaged.

Why is Aid given!

The obvious answer is that developing countries need it to improve the nutrition, health and education of their populations and western countries feel there is a moral imperative for them to provide the resources and expertise to help achieve these aims. However this probably is a too simplistic explanation.

I recently read an amazing book on the life and motivations of Mao Tse Tung by Jung Chang and her husband Jon Halliday. Jung also wrote Wild Swans. She clearly had a great dislike of Mao who, she says gave very large amounts of aid mainly in the form of food to other countries including those richer than China, simply for political purposes and that this caused great hardship and starvation to millions of his own people. Jing Jaing claims that Chinese aid was given simply to increase Mao's personal standing and China’s influence in the world. To make Mao and China first world powers.

It would be naïve not to recognize that cultivating good relationships between politicians from first and third world countries is a major reason for giving aid but it may be more important than any western politician would like to admit to its voters! Half of VSO’s budget is from the British government and it is probably important for its volunteers to fully understand what the British government’s real expectations are from this expenditure. It is clearly different from Mao Tse Tung’s aims and probably closer to the altruism of many of VSO volunteers but what does it actually achieve? It may be cynical to suggest that at worst VSO volunteers may be simply instruments of British foreign policy and are sent to persuade Zambians that the British are more to be trusted than the Chinese when they decide who should rebuild their disintegrating roads!
This doesn’t mean that aid should not be given although I think we should always be willing to consider a default position that it might be safer to let Africans run their own countries without our interference through ‘aid’ which may cause 'harm as well good'! Western countries need to be know and make their own populations aware how aid does harm as well as good.

I hope this rather cynical view results in a better understanding of how to avoid some of the pitfalls of giving aid. This will increase the chance that our endeavors will achieve some benefit while minimizing the harm that inevitably occasionally accompanies some of our best intentions.

What has ‘Aid’ achieved so far apart from some good relationships?

It is best to review some simple facts about the 'old and new' ways of helping Africa before we allow prejudices to cloud our opinions!

It is generally accepted that colonialism failed mainly on the basis that a minority of the population running a country wasn’t just in a modern world nor was it sustainable.

However it is also manifestly clear that the old system of helping Africa starting with David Livingstone and christian missionaries in the 19th century did achieve a great deal in terms of building an infrastructure essential for any modern successful nation. It also introduced a christian culture which may be much more important than we imagine for Africans to achieve the high standard of living that Western countries have developed.

Roads, railways, power, electricity, clean water and education for children, a reasonably efficient uncorrupt civil service that is respectful to its population and law and order are all essential elements of our world which have evolved over a long period of time at a pace which has been synchronised to its creation of wealth without any interference from other countries. The colonial system certainly created a very sound economic system which provided the basics for many Africans including secure food, successful healthcare and the beginnings of high quality education. It is clear in Zambia, which I think is typical of most other countries in sub-Saharan Africa that most of these essential aspects of a modern state have deteriorated since independence in 1964. This is without contention and is physically obvious in our daily lives some of which has been documented in our blogs. This deterioration has occurred in spite of huge amounts of aid from first world countries, the newest way to help Africa since the end of the colonial period.

The main roads in Zambia even to the main tourist areas such as Livingstone are appalling and no or very few roads have been built since independence. It is clear that many of the local roads in Monze, which after the wet season were easier to navigate on foot, have not been maintained since independence and some will soon completely disappear.

The railway system in East Africa, which was something to be proud of, is just re-emerging mainly for tourists. The journey from Livingstone to Lusaka that used to be achieved in less than a day now takes over 3 days.

This means the disintegrating roads, parts of which have been badly repaired with Chinese aid which persists long since Mao’s death has to support most of the transport of heavy goods such as copper in huge lorries. These travel on narrow strips of tarmac at great and dangerous speeds taking out cars, bikes and people or breaking down to produce another form of obstructive danger and together with other aspects of Zambian life, create one of the main burdens for the healthcare system, trauma.

Education is delivered by poorly motivated under paid teachers who have to do second jobs to achieve a living standard they have been educated to expect. Although large numbers of children attend schools on a three-shift system,

which is highly encouraging, the quality of teaching they get is uncertain. What does happen is that some classes are left alone for long periods of time while their teachers are doing their second jobs!

The civil service is probably overburdened or suffering serious morale problems so that even the local people are treated with disrespect unless they have a relative working in the system.

These observations have been supported by conversations I’ve had with a few older and experienced Zambians.

One was an ex-policeman from colonial times, now with HIV who we met at his home in a sub-urban township with his wife and sons. He lived in considerable poverty even by Zambian standards and was full of praise for the discipline and order of the colonial period which he said was now lost and that the society and the police force was the worse for this.

Another was a magistrate who was at one time close to Kenneth Kaunda, Zambia’s first president after independence and had been politician. He had been invited back into politics but refused because he felt the old ethos of honesty and ethics in politics of the KK period had disappeared and felt that the current politicians were corrupt and only into politics for what money and power they could get. He was my patient for a time and while visiting our home he saw the photos of our family on the walls and became very wistful when he heard what they were doing and what things we did together and said this was never possible in his own family although they were close. Overall he judged his countrymen very harshly.

Another politician we have written about in an earlier blog, who we met in Shakalima bar just up the road and who lives part of the time in a local village had been in KK’s cabinet and had very similar sentiments.

The new system used by western countries to support independent African states, which was supposed to be better than the 'colonial way' , by giving aid in the form of physical resources and cash has been equally unsuccessful. It has probably preserved many of the less savoury motivations without some of the purer altruistic drives which undoubtedly were part of the old colonial package. We saw remnants of this in the remaining ex-pats such as Jill and Mike Bennett

Jill, Mike and Mike

and other white farmers, the Irish nuns and a few white doctors who have devoted their lives to Africa. We are at a point in time that we can look back at all the good things of the colonial period while seeing the bad results of the new system of supporting independent African states with aid.

Why has aid failed in sub-Saharan Africa?

Most people accept that any intervention no matter how well meant will do harm as well as good but with aid it is assumed, often without any evidence that the benefits will far outweigh the inevitable harm and little effort is made by aid agencies to make sure their systems to monitor and evaluate their programmes are giving them accurate information particularly the damage it may be creating.
Most NGOs are aware of the dangers of creating dependency and of achieving change that isn’t sustainable but most are not aware of the very serious harm aid can inflict to an extent that its end result is to achieve the complete reverse of it’s original aims. ‘Bad’ aid not only slows development it makes it more difficult to achieve change in the future. The default position of letting Africans proceed at their own slower pace of development may be far better than giving poorly planned aid, which makes no attempt to identify and avoid its potential pitfalls.
While working in HIV/AIDS service in Monze, we have seen two examples of how aid can do more harm than good and a third where it’s advantages weren’t straightforward
It seems self evident that giving food to HIV/AIDS patients must be good, that giving money for expenses to encourage and recruit volunteers who provide home based care for these patients in the community and for orphaned and vulnerable children is a Christian duty and that supplying free anti-retroviral therapy will be a great contribution to controlling HIV/AIDS in Africa. However these well meant interventions have caused serious problems for the HIV/AIDS service in Monze and in such a corrosive way that any benefit there could have been has been greatly outweighed by there disadvantages.

1. Paying volunteers expenses.

CHAZ (Churches Health Association Zambia) an NGO have given a lot of money to the accounts department at Monze Mission Hospital for volunteer’s expenses arising out of home based care. Just before we arrived 4 senior members of the HIV/AIDS service including the senior accountant were arrested by the police for putting a lot of this money into there own pockets. Although only the senior accounts manager was convicted the effect on the morale of the whole department meant that there have been no further essential, urgently needed changes to the service and virtually no leadership for over 6 months. The department that we and Dunn our Monitoring and Evaluation VSO colleague had been placed to help was in effect deflected from trying to resolve the problems for 6 months while waiting for the result of the court procedings. Patients continue to be seen in difficult circumstances, with crowded clinics,

long waits, no privacy and little or no support in the community. The volunteers who should have received the cash are angry, have had to come to Monze Magistrates Court on at least 2 occasions to give evidence during which time, because their homes are some distance from Monze they have to camp out and have been severely de-motivated by the whole episode.

Home based carers teaching session showing the volunteers on which the delivery of the HIV/AIDS care in Monze is so dependant.

It is not known what the court case has done for recruitment of further volunteers. It has created bad relationships between the hospital managers and the volunteers and the loss of trust will take a long time to restore. All because of the admirable altruistic impulses of western christian aid. It would be wrong to assume this episode is at all rare.

In other HIV/AIDS services such as Lundazi in eastern Zambia volunteers do not have expenses, they do the work for their fellow man out of love and concern for their community and these problems have not occurred. It would have been better in Monze if the money had never been offered, the ‘default position’ and the service be allowed to develop at its own natural pace without interference from aid. The time now being taken to solve these problems is significant and could have been better spent addressing all the other naturally occurring problems created by an HIV/AIDS service.

2. Food for Patients

There is some evidence that giving food to HIV patients improves outcomes but the overall effect is probably small especially in well nourished patients. Providing food for these patients has been a major aim of CHAZ churches health association of Zambia.

The problem is that CHAZ did not have enough food for all patients or for some patients all the time. The end result of this is that some patients coming to the clinic expecting food were extremely angry with the doctor who had to refuse and in patients getting food, when it ceased they were very resentful as were their relatives and even the friends in their village. On our visits to patient’s homes we met perfectly healthy and well-fed angry relatives expecting free food and others living in the countryside were growing less maize because of the gift. Perhaps predictably the HIV patient’s family rather than the patient ate much of the donated food and there is no way of stopping this!
Most of the HIV patients in Monze aren’t short of food and those that are malnourished, this is mainly due to the virus not a lack of food.
Much time was also spent by the medical staff on a departmental policy to determine a fair way to distribute the food based on a thorough clinical assessment of the patient’s nutritional status and whether the home based carers, dieticians and social workers should also be involved in the decision. This policy was so top heavy it was never used and all patients wanting food had to see the poor medical licentiate Mr. Mazabuka Kerridge who runs the department who became very unpopular by having to say no to patients damaging the important patient doctor relationship and making Mazabuka’s work very stressful.

Two children visiting the food distribution centre. It must be the mango season!

It was also discovered that the guys delivering the sacs of mealy meal were demanding a cut of the delivery! Three sacs of MM from every delivery.

The end result of this Christian act was unhappy patients, relatives and doctors and much wasted time in discussing the problem and preparing policy documents all of which were never used. It wouldn’t be an unfair assessment to say the overall result was deeply negative and who would argue that the ‘default position’, no food, would have been better at least for Monze?

3. Free Anti-retroviral therapy (ART)

There is no question that for virtually all patients ART is fantastic. The UN is now predicting it will prolong the lives of young patients for up to 25yrs, many of whom have several children which means many children will now not be orphaned. It reduces the viral load making patients less infective, which could actually reduce the spread of the virus and the number of people getting infected. However ART, in reducing the fear of AIDs is removing one of the greatest drives to persuade people to adopt safe sexual practices, the only guaranteed way of stopping the epidemic! HIV/AIDS is now treatable! If the overall prevalence of the disease isn’t reduced by changes in sexual behaviour the cost of treating HIV/AIDS will increase and continue to consume a significant part of the health resources in developing countries both in terms of trained medical staff and cash that could be deployed to other areas. Providing free ART drugs could create enormous economic difficulties in other areas of healthcare delivery for developing countries!

We have just heard from a social anthropologist that that although young male Africans are terrified of getting HIV/AIDS and have taken some measures they believe will reduce their risk, like washing before and after sex they are taking virtually no genuinely effective measures. The girls aren’t able to say no although older women apparently do and presumably the husband simply takes a younger wife. The pressures to change sexual behaviour remain weak and ART could weaken this further as it has apparently in the American gay community.
No one is quite sure why HIV/AIDS has been a bigger problem in southern Africa than in other parts of the world but it is likely to be due to differences in sexual behaviour and not necessarily just more promiscuity, perhaps by having several partners at one time rather than serial monogamy as in the west. Whatever the cause of the epidemic, effective treatments will also weaken young Africans resolve to change their behaviour.
The bottom line for the prevention of HIV/AIDS is ABC: Abstinence, Be faithful and if you can’t be good be Careful, use Condoms.

Some young patients are abandoning ABC because they think HIV can be cured if they get it, so why bother!

Treating HIV is also making it possible for young adults to continue to have children creating another cascade of problems not only how to prevent the babies getting HIV during the pregnancy, delivery and breast feeding but who should be left with the responsibility for the economic and social health of the children if their parents die of AIDS and how fair is it to burden a baby and child with life long ARV treatment if the babies are infected. It is doubtful how much the very young and poorly educated adults who have to make these decisions fully understand the issues.
Few patients know that the drugs are expensive and paid for by western charities and this can lead to irresponsible use of the drugs leading to poor adherence and the development of resistant strains of virus. Most patients are completely unaware of the significant long-term damage these drugs can inflict on patients.
The development of ART is a great step forward in reducing the anguish of HIV/AIDS but it is important to be aware of all the pitfalls of introducing this powerful treatment if we are to minimize its disadvantages. If the prevalence of HIV infection is not reduced the end result of free ARV therapy may be to severely damage other African health services, which already cannot cope with the current work load!

Conclusion

We have read two books (1,2), which also conclude that it is time to adopt the default position in Africa, to stop giving aid in the way we do and search for other ways of helping Africa in a post colonial and aid world!
I think this is extreme but I think it is essential to learn from our current mistakes. The west is currently at risk of committing greater sins than they achieved in the colonial era and they may be less altruistic in their aims than they claim to be.
The key to this is to have a better understanding of the differences in cultures between the developed and non-developed countries and how this results in the many blocks to change.

Meeting and working in Zambia for a year has shown us that on a personal level we are all the same and that there is no reason why Zambians shouldn't create a society as rich and materially successful as ours. I believe that one of the main blocks to development is because of our different mind sets which our respective cultures have created in the majority of people in our countries and perhaps we misjudge the time it takes for cultural attitudes to change. Although individuals can change in one generation it seems a whole societies deeply rooted beliefs take longer to change. Unless we understand the powerful effect our christian culture has had on the way we have created wealth and slowly changed our attitudes to work and life and the way we behave over 200 years and try and understand why and how African culture has evolved and the way it has influenced their approach to life we will continue to make the same mistakes we have made in our attempts to help Africa and since.
We have been privileged to live for 2 years in America and now 1 year in Africa and we have become convinced that culture has a much greater effect on the way we behave than we previously assumed and that the answer to many of the problems of helping the developing world lies in understanding how these differences have arisen.

More of this in a later blog, which we will do after more time for reflection and probably after we have arrived back in the UK .

1. Lords of Poverty: the power,prestige and corruption of the international aid business. Graham Hancock. The Atlantic monthly press, New York.

2. Dead Aid: Why aid is not working and how there is another way for Africa. Dambisa Moyo.

The next few blogs will be based on our holiday with Emma and then on our months journey through north eastern Zambia, Lake Tanganyika and northern Tanzania on our way back to the UK!