Contemplating Calamity

This was written in July 2005 in Tanzania


So far all of my work has been in the City and not in the rural provinces and for that I’m relieved in one way because the time pressures to complete the writing are great.

On the other hand, a part of me misses seeing basic primary healthcare provided in a rural dispensary without electricity or running water. It misses the wonderment of glimpsing women trudging miles to fetch water and maybe a few twigs to make a fire and knowing that they do that every day and always will. What I don’t miss is hearing there is no water or if there is that an “entrepreneur” has decided that he will collect a few shillings for the privilege of letting you take water from the stream - or if you have no money – well, you can imagine what the barter system means then. I don’t miss the look of hopelessness on the faces of these women, as they know they will probably become one more statistic to the “skinny disease”.

I miss seeing real humanitarians – not people like me who come and go – but people who came and stayed, stayed because this was the life they chose.

I miss traveling to the villages and visiting with old women with young children gathered around - what I don’t miss is knowing that the children are orphaned from AIDS; that most of them are positive and that she is one of the few adults left alive.

One of the aspects of Public Health that takes some getting used to is that the needs of the many are what drive your efforts and sometimes the needs of the few or the one cannot be answered.

I met a young woman last time I was here; an Irish Doctor, a Nun, who has been here 35 years, introduced her to me. She was HIV positive – not AIDS yet – but nevertheless…She had been a grad student in Greece when she was screened for HIV and found to be positive. The Greek government gave her a 6-month supply of ARV drugs and sent her back home to Tanzania. She told me she had sold the drugs here in Dar! I was speechless. This was an educated, well-spoken woman who knew full well what she was doing and yet that allowed her make that decision. She explained that her family could never have afforded the drugs after the six-month supply was finished, assuming that the type of pharmaceutical was even available in Dar. On the other hand, she could (and did) sell the drugs to a wealthy family and use the money to make her family a little better off.

I knew that her raison d'être was logical; this is East Africa, and accordingly I had to accept her judgment. That still did not make it any easier as we sat there and quietly drank coffee together. She has passed away.

She was the “one” - the “few” - and as for the needs of the many? - I know that someone (not me of course) but someone can and will find a way to stop this scourge. If I did not believe that I would certainly go mad.

Bill Clinton is coming here today; he was in Lesotho yesterday. Lesotho is a small country, completely surrounded by South Africa to whom it “exports” water when there is a drought. There has not been one in a few years now. Clinton told the people there that unless they took drastic measures to curb the rate of HIV infection that their country would cease to exist – reflect on that! A country wiped out, not by war or nuclear winters but by a pestilence that is biblical in proportion. He is right.

Governments must be honest with the scale and intensity of this epidemic.
Tanzania reports HIV solely from voluntary testing and blood donors. Consider the futility of that process in a country with a per-capita income less than the cost of tickets for a Broadway play. Do they really believe that they can accurately estimate the incursion by these simplistic methods? They know better of course but this is an election year and so we hear figures like 4% and 6% - when the reality is probably five times that. The cause of death statistics shows almost no HIV occurrences, partly because of the lack of clinical algorithms to diagnose but also the embarrassment to the families. Yet everyone knows the truth; it is just not spoken.

The very fabric of society is disintegrating as we watch - in a way like we watched the genocide in Rwanda or the horrifying policies of Mugabe in Zimbabwe. Civil servants leave rural postings out of fear; farmers die before they can teach the next generation; teachers die and cannot be replaced; mothers and fathers die; and young girls die because men are…I don’t even know the word.

Is there a future for Lesotho and Malawi and Botswana and Tanzania and so many other places? I don’t know. Perhaps the people and these political entities will quietly disappear into history, the weeping of the “few” being the only sounds to linger.

It has happened before on this terribly beautiful continent.; Conrad’s Africa had a heart but now it is bleeding.

Dar-es-Salaam, Tanzania
July 2005