The coolness of the early morning greeted me as I set off for the northeastern part of Namibia. Cruising at 12,000 feet, the unpressurized cabin filled with the muffled sound of its dual engines. The vast and desolate landscape sped by beneath us as the rising sun ushered in the new day. My destination was Katima Mulilo, a small Namibian town located on a 250 mile panhandle called the Caprivi Strip. In the late 1990’s the Peace Corp and other development agencies evacuated foreign staff after violence escalated in the region. During this period, Caprivian separatists articulated through words and actions their aim to set up a sovereign state. They vowed to give their lives for their independence, their freedom.
By the time I landed in Caprivi, the day was beginning to heat up. Although it was winter, temperatures easily reached into the 80’s. After waiting about 30 minutes, a taxi eventually pulled up and a young woman climbed out. In a heavily accented greeting we exchanged hellos and uncomfortable half-smiles that strangers often share when words are lost. As we drove into town, I realized my host had perhaps only made this trip a handful of times, if ever. Not only was the cost of an airplane ticket an extraordinary figure to pay for the majority of those living in and around Katima, but the US $7 taxi fare was similarly too steep for most to afford.
The drive into town exposed the dry landscape. High standing termite mounds protruded from the ground. The roadside was sprinkled with those walking to and from town from a local village. Some carried containers for water; others carried wood for fuel. There were men who walked steadily with emaciated cows and others who unenthusiastically worked the road as part of a maintenance and repair detail. I had traveled to Katima to document a health outreach program for youth at a secondary school. The school is located southeast of Katima at a border post called Ngoma. Just south of Ngoma, past the boundary lands, lies Botswana, and to the north across the Zambezi River is Zambia. The secondary school is set off from the highway, hidden to some degree behind several small trees and a series of shebeens (bars). The area itself is a major commercial and tourist thoroughfare. Trucks are often making the long journey to the Namibian coast where their cargo will be sent by ship to other regions in Africa and to Europe. A majority of the tourists have hired cars and are en-route to Victoria Falls in Zimbabwe where an elaborate established ecotourism industry exists.
HIV/AIDS, Opportunistic Infections, and Testing
Since its discovery in the early 1980’s, the international community has learned that the virus which causes AIDS destroys the body’s natural ability to fight off illness. Once infected, there is an asymptomatic stage in which an individual can live with HIV without clinically presenting. However, once the body’s immune system is sufficiently compromised, to the point of no longer being able to fight off infection, a person will fall sick and will ultimately succumb to any number of opportunistic infections (e.g. pneumonia, tuberculosis). One of the major concerns regarding HIV infection is the window of time when a person is infectious before they are sick with AIDS. If an infected person does not know their HIV status, they are then unaware that they may be contributing to the epidemic’s expansion by passing it on to others. For this reason, efforts are underway in Namibia and around the world to dramatically scale-up voluntary counseling and testing services (VCT). Evidence has shown that abstinence is the only sure way to stop the spread of the virus. However, in a world where few follow such practices, condom use can significantly reduce one’s risk of acquiring sexually transmitted diseases such as HIV.
A Staggering Statistic
Nearly half of the population is infected with HIV. Prior to my departure, I was briefed on some of the major issues currently at work in Katima and Ngoma – extreme poverty, lack of education and gender inequality. The most striking part of my briefing was the staggering HIV prevalence of the region which has been estimated to be approximately 43 percent. In Namibia, HIV epidemiologic surveillance data is obtained through testing the blood of pregnant women visiting antenatal clinics. At a level where nearly 50 percent of the population is infected by HIV, no one is spared from the burden of this syndrome. Those infected in Katima include teachers, entrepreneurs, government officials, religious ministers, tribal leaders, nurses, and doctors. They are the people who build and maintain roads, who work in shops, and who sell meat at the market. They are the old people who sit in the shade, the women carrying sticks on their heads with their babies wrapped tightly on their backs. They are the kids playing in the dry dirt and the fishermen returning triumphant from the river’s edge. They are the African rappers whose rhythmic gesticulation rocks you to the pounding beat. And they are those who are most vulnerable—mothers, girls, and infants.
In Katima, AIDS medicines called antiretrovirals (ARV) used in a drug regime called HAART (Highly Active Antiretroviral Therapy) are inaccessible by local people because of their high cost on one hand and the lack of political will and commitment to provide the drugs on the other. HAART reduces HIV’s ability to replicate itself and indirectly strengthens the body’s immune defense against the barrage of pathogens that cause sickness. As the world has learned, without these very effective drugs, life expectancy for those living with HIV is short and will depend on a number of variables, including access to clean water and sanitation, proper nutrition and appropriate hygiene standards. The advent of ARVs within the last X-number-of years offered the world more than a highly effective drug which brought people back from the brink of death. ARVs single handedly restored something that had been violently taken away from those infected with HIV, and the many family, friends and caregivers which comprised the infected’s social structure: ARVs renewed a sense of hope that for a period of time had been lost.
Many have speculated as to the reasons why Katima has such a high rate of infection compared to the national average that is estimated to be between 18.2 to 24.7 percent. Speculators suggest that deeply ingrained cultural practices are fueling the epidemic. These practices focus on the fact that most men are known to have multiple sexual partners and are passing the virus on to women and girls. Others suggest that mobile populations such as lorry drivers (truckers) are literally driving HIV across national borders, particularly from countries with national rates equal to or higher than Namibia’s: Botswana (37.3%), Zambia (16.5%), and Zimbabwe (24.6%). Inadequate education and extreme poverty are also known risk factors.
Women and Girls: Social and Biologic Vulnerabilities
The plight of woman in the wake of an expanding epidemic has received increased attention over the last several years. Both in 1990 and 2004 the theme of World AIDS Day, annually observed on December 1st, focused on women and girls. Numerous scientific papers and media reports have pointedly noted the feminization of the HIV/AIDS pandemic and that the face of AIDS—once perceived to be that of a white gay male—increasingly resembles a non-white female. AVERT, an international AIDS Charity noted that “just under two-thirds of all people infected with HIV are living in Sub-Saharan Africa, 57% of whom are women. Around 76% of young people here who are infected with HIV are female.” In an editorial by the New York Times, the paper reported on figures from UNAIDS, the UN agency which monitors the HIV/AIDS epidemic, that in sub-Saharan Africa, women aged 15 to 24 are three times more likely to be infected with HIV than their male counterparts. And in Thailand, at the height of their epidemic some 90 percent of commercial sex workers were found to be HIV positive.
As India, China, and Eastern Europe fully emerge as the next wave of countries thought to bear the brunt of the pandemic, the face of HIV/AIDS will continue to deepen and reflect the diversity and extent to how this global problem has expanded and touched those who are most vulnerable.
At play are the ubiquitous gender imbalances which circle the globe and place women and girls at greater risk of being infected with HIV. Women and girls in virtually every corner of the world have fewer rights than men. In many settings, they are unable to negotiate when, how often, or with whom they have sex. As a result, women and girls are placed at higher risk of contracting HIV and other sexually transmitted diseases (STDs). Girls and women are also often prevented from going to school, participating as full members in local economies, and accessing even the most basic health care services. Because of these and many other issues, women are barred from any true independence from men and within their society.
A female’s anatomy, especially a young girl’s, puts her at a higher risk of being infected with HIV than men and boys. Because of genital surface area, females have a greater risk of exposure to sexually transmitted pathogens like HIV. Additionally, prior to puberty, girls are less physiologically developed and are therefore more susceptible to vaginal tearing which increases one’s susceptibility to infection. Rape and myth have played a major role in a girl’s HIV risk in sub-Saharan Africa. It is well documented that a circulating Southern African myth suggest that if a man has sex with a virgin he will be cured of his ailments. If myths such as these and gender equality are not frontally addressed, women and girls will continue to be victims in a cycle of violence which has them squarely in its crosshairs.
If anything, Ngoma was a snapshot of the confluence of variables and factors which the medical, social science, and development community were attempting to explain through words, data, and images. We arrived at the senior secondary school in the middle of the afternoon. In the cool of the shade, we parked the van under a tree and took a couple of minutes to snack on chips and drink cool sodas. The school was made up of a dozen standalone buildings. The classrooms established an ad hoc courtyard with a medium sized tree at its center. By the afternoon’s end, in the warm amber of the sun, the red of the tree’s fruit stood out like the quick articulated strokes of an impressionist’s painting.
The principle reason the health education team had come to Ngoma was because of the schools’ proximity to the border post, its shebeens, and the steady traffic across the border. It is well known that students at the school struggle with serious life and health issues. Teenage pregnancy is on the rise as well as fear of their increased risk to HIV infection. Children as young as twelve have babies and of the 300 students, a third of them have been orphaned by HIV/AIDS, where either one or both parents have succumbed to the virus. In so many ways this clearly exemplifies what Helen Epstein recently characterized in the New York Book Review as an era of “the lost children of AIDS.”
The Outreach: Edutainment
The team that conducted the health outreach practiced a method called edutainment, one part education and one part entertainment. Two of the educators performed a comedic skit where the students observed a married couple arguing over the husband’s infidelity. The skit intelligently approached a serious topic for discussion with an ample sharing of poignant comedy. For me, it was striking to observe people I had recently met command such presence when discussing issues that were literally tearing their society apart. It wasn’t until half way through the edutainment that I began to consider the afternoon’s proceedings. What stood before me was a group of students, most wearing the traditional grays and whites of the Namibian school uniform. They sat in poorly structured rows facing the edutainment team, boys to one side, girls to the other. They were young people with their own dreams and aspirations, who laughed and who conceivably cried. They were remarkably forthcoming and seemed to know much of the curriculum that was being presented to them. Scores of hands would quickly rise when asked if they knew what the letters H-I-V represented or how they could protect themselves from the virus. In their more traditional training, each student would stand to answer a question. If they didn’t answer the question correctly, they were chided by their peers and forced to sit down quickly or face an avalanche of jocular chastisement. In the comfortable environment created through the edutainment, the students were free to share their thoughts and dreams.
A 15 year old student explained that her dream was to finish school, find a good job, and then get married. She noted that her dream would not be realized if she became pregnant or horribly sick with AIDS. Another student explained that the workshop was important because students had to know how HIV is transmitted from person to person. At 19, he spoke of the harsh reality HIV/AIDS had on his family and friends. Before he ran off with his friends after the session, he suggested that if there is to be any change, boys have to encourage their friends to protect themselves through condom use and getting tested.
The edutainment also focused on the issue of abstinence. Although the students had been well trained to recognize condoms as an important means by which to protect themselves, abstinence was also an option that young people needed to be aware of and exercise. It was iterated over and over that girls need to know that they have the option and ability to say no to sexual predation from both their peers and older men. By the end of the outreach, I was moved by the work of the educators while at the same time torn by the focus on abstinence. I was conflicted because abstinence on its own cannot save lives but it is an important part of a global message about STD and HIV prevention. Research has shown that through a balanced approach of offering the ABC’s (Abstinence, Being faithful to one partner, and Condom use and HIV testing) an individual can take appropriate steps to modify their behavior so as to reduce their risk of contracting an STD.
In recent years, the health development community has come up against competing ideologies with advocates on one side supporting abstinence focused programming and social and behavioral scientist on the other side, holding up the ABC framework as the best and more comprehensive plan. What is needed are well educated people, young and old who are trained in the ABCs and who can then make up their minds as to which plan of action they want to take. If we are students of history and human behavior, then we know that neither abstinence nor being faithful to one partner nor condom use will be practiced with the due diligence that is currently required. By equipping these young people with a full rather than partial knowledge, the health development community can empower rather than detract from an individual’s choice.
Any preconceived notion I had of Katima and Ngoma was a mixture of what I had been told and the fanciful adlib the mind conjures when it attempts to construct a mental picture of a place it has never experienced. What I found in the far northeastern corner of a place far from my home were human beings challenged to live and thrive. What I saw made me proud to be doing work that in some small way would hopefully save a life. Of course, the statistics are not in favor of the students at Ngoma or Katima. If anything, many will be parents in the next couple of years and many will die of AIDS. But for the small few, for the lucky ones, they will be called upon to forge new paths in a nation and on a continent that will require leaders, teachers, and doctors. They will be challenged to pick up the pieces and carry on in a world that has been slow to respond to their needs. I expect that one day the international community will fully recognize that millions of people die of preventable disease such as measles, diarrhea, TB, and HIV/AIDS. Many of these diseases have vaccines, medicines, or prophylaxes that are available but are not reaching the world’s poor.
It has been said that in nations like the United States, we are experiencing AIDS fatigue in that after 25 years of talking about AIDS there is a need to take a break and focus on something else for a while. Perhaps the critics are correct. HIV/AIDS is no longer the sexy new emerging disease it once was. But let us not forget that since the 1980’s, 60 million people have become infected or have died of HIV and AIDS. Despite all that, we have learned and developed, the epidemic is worsening, expanding to new regions and new populations globally. In considering HIV’s expansion into China and India, with roughly one third of the world’s population (>2 billion people), HIV/AIDS has the potential to outpace what has already transpired in the last two decades. The lessons learned in Ngoma are similar to stories you may hear from the Ukraine, China, India, Botswana, Brazil, and the Americas. They are the stories of a disease which characterize human behavior and the imbalance of power in societies and among individuals. To address HIV/AIDS is not solely to treat the symptoms of this deadly disease but to understand the reasons why it has been permitted to expand – almost unmitigated.