Wednesday, August 13, 2008


Last week I had two experiences which shed more light on the HIV situation in Swaziland for me. A couple of colleagues and I were invited to spend our lunch hours at an orphanage in Mbabane this past Wednesday, and on Friday we toured an HIV clinic on the outskirts of town here.

HIV / AIDS is a huge issue in Africa in general, and Swaziland in particular. It’s the number one problem that this country and continent face, and it’s claiming millions of lives. Swaziland has been particularly affected, and until recently had the unhappy distinction of having the highest HIV infection rate in the world (39-42%, depending on the survey – and that’s the official percentage for those who have been tested; estimates are much higher – 60% or more – for the general population), and the shortest life expectancy of any nation in the world (32).

The country hasn’t dealt with the problem effectively. A few years back the official HIV strategy announced by the King was a four-year prohibition of sex for all women under a certain age, a ban which the King broke several times. Through polygamy, lack of robust prevention policies and health care, and the stigma of the disease, HIV spread and has devastated the country.

While I don’t see the impact of HIV directly through my work, it’s impossible to be in Swaziland and not see the reach of the disease. There are things that you notice right away – all throughout the country the population is very young; there are relatively few elders. And there are tons of children – mainly HIV orphans – all throughout the country, and especially in the rural areas. Single mothers or grandmothers become caregivers for six, eight, ten or more children. They have few ways to earn money, and little resources to pay for food, clothes, and school fees. It makes the job of raising a child, the experience of growing up, and the prospect of lifting a country out of poverty extremely difficult propositions.

Working for TechnoServe in Mbabane, I’m a bit removed from seeing the impact of HIV. A Swazi colleague, Gail, took a few of us in the office to tour an orphanage where she volunteers. The orphanage was run by a US expat from Alaska, who came to Swaziland as a pediatric nurse and ended up moving here with her husband and taking on this project. Many of the twenty-one children were HIV orphans.

The orphanage was a really great facility. Most of the children are between two and five (with one or two older children) and were taken into the orphanage when they were very young. They live in one of three houses, each with a House Mother who is their primary caregiver. There was a shared playroom and nursery school, and the houses were clean and cheerful. The orphanage has a lot of local support and connections for supplying good, healthy food, and the expat who leads the project receives sufficient funding, mostly from the states. From Gail’s judgment, it seemed to be one of the best-equipped, well-run orphanages in Swaziland.

Visiting the HIV clinic was a similar experience. I’ve met a number of doctors who are working here through the Baylor International Pediatric AIDS Initiative, and two of my neighbors – Peluca and Lucia – are Spanish doctors working at the clinic. Peluca and Lucia gave us a tour of the clinic last Friday. Unfortunately, on Friday the clinic is closed to patients, but we got a good look at the building – the most modern building I’ve seen yet in Swaziland, well on par with or beyond many of the medical facilities being used in the U.S. – and a bit of a background about the epidemic.

The clinic provides care to any HIV positive child up to 15 years old, and their caregivers - parents, grandparents, guardians, etc. (Like all clinics in Africa, HIV care is delivered free of charge.) While the clinic is meant to test, diagnose, and treat HIV, they also end up providing general medical care for these children and their families.

We saw what may have been the best HIV and orphanage facilities in the country, which painted a rosy picture of the epidemic. Rosy or not, there are a couple of things that are clear about AIDS and HIV.

The first is that the epidemic needs to be controlled before any meaningful progress – economic, social, or otherwise – could take place in Swaziland. Meaningful economic development will continue to take a back seat to AIDS in Swaziland for a while; it’s hard to promote business and an entrepreneurial culture on a large scale in an environment where family structures are destroyed, caregivers have eight or more children to tend to, the life expectancy is so low, and education gets a back-seat due to HIV. While there are a number of different organizations here involved in HIV/AIDS, TechnoServe is the only non-Swazi NGO in the economic development space. Unfortunately Swaziland does not seem to be on the shortlist of countries to enter for many other development organizations or foreign direct investment.

The second, more encouraging, thing is that the crisis is now in the forefront, and there are huge efforts and big money behind prevention and treatment efforts. Looking at the Baylor facility and speaking with Peluca and Lucia, it’s clear that there’s money available, mainly from major foundations in the US and Europe. Swaziland has also embraced prevention efforts – billboards here promote monogamy, safe sex, or compliance with treatment options; free condoms are offered in office bathrooms, at government offices, and border crossings; images of red ribbons are common on newspapers and official documents; and there are constant reminders and announcements at concerts and events. Awareness is now embedded in the culture here.

Despite the money and promotion, beating AIDS here is a monster task, and implementation is extremely difficult. The doctors at Baylor face treatment compliance/adherence problems (patients may not take pills, and often don’t come to the clinic as needed because of high transportation costs, etc.), government bureaucracy (connecting the Baylor database with the Mbabane hospital DB has been a real problem), and social problems (a big stigma still persists). They’re optimistic, but also realistic about the enormity of the problem. A number of Peace Corps volunteers I’ve met, who are stationed in the countryside, are less optimistic, as they’ve been close to the problem and have spent too many days attending funerals in their villages. It’s a rural country, and a number of the PC volunteers have written off the development prospects for Swaziland as a whole.

I’m reminded of a speech a few years ago by a former US Ambassador to the UN whose name I can’t remember and whose speech I can’t find online. In the speech he asks how could the West have turned their eyes to the crisis that was unfolding in Africa, and the millions of lives being lost. It’s clear that there’s attention on the problem now, but there’s a lot of work to do.

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