I TRAVELLED to Israel recently and I was amazed.
The country has little fresh water, is largely desert, it has no minerals to speak off and no oil.
It is smaller than the Copperbelt Province and has a population of less than three quarters that of Zambia, and yet it has a per capita income 20 times that of Zambia. It is also one of the largest exporters of cherry tomatoes in the world.
I wondered how a country could achieve so much with so little. So I invested a little in what reading materials I could find on this subject . Through this I became aware of the book by Dan Senor and Saul Singer called “A start up nation”.
I was quickly struck by the frequently quoted explanation by the former Israeli Prime Minister and later President Shimon Peres. He describes the basis of this success in one word, simply called “dissatisfaction”.
That restlessness of a nation that makes people unwilling to accept the circumstances they find themselves in, but the energy and drive to achieve more and to do better. If I was to reverse this onto Africa, I would use the word “satisfaction” or perhaps complacency, as the reason, why we have not done better. The phrase is often quoted “necessity is the mother of invention”.
More coarsely put, the misfortune of abundance is the curse of self-indulgence. If we take the case of Zambia, we have an abundance of fresh water (40 per cent of the water in the Southern African Development Community region), minerals(the 4th largest producer of copper) and land(one of largest abundance of arable land in Africa).
How does all this relate to the issue of health?
One of the major health burdens in Zambia and Africa is HIV infection. So if I’ll take the case of HIV and tell its story in Zambia, perhaps you will agree with me, that you and I , have been guilty of complacency.
1.What is story of HIV?
According to the recent demography health survey of 2014 the HIV prevalence has decreased from 16 per cent in 2001 to 13 per cent in 2014. This may be tampered by other factors, such as those that are dying or living longer from HIV. Taking this into account these figures may not reflect an accurate picture of the status of the disease. Therefore, the more telling fact is the HIV prevalence among young people which was 4.7 per cent in 2007 and is now 4.4 per cent in 2014. This is a more sensitive indicator of whether we are reducing the number of new infections in Zambia or not. In fact a closer look at the data shows that though there has been a decline in new infections among girls (5.7 per cent in 2007 to 4.7 per cent in 2014), there has been an increases among boys (3.6 per cent in 2007 to 4.1 per cent in 2014).
HIV was first recognised in the 1980s among homosexuals in San Francisco in the US, at the time many sermons were preached in Zambia about Gods punishment, and I listened to some.
In the early 1980s it came into East Africa and spread among the trade routes through East Africa to Southern Africa. It was not until 1986 that the first few cases were reported in Zambia. The initial feeling was that this was a disease of homosexuals, very far away in America.
When it came to East Africa, it was still felt as foreign, or belonging to another region. When gradually the disease spread through to Zambia, it was still felt to be a disease of others. The high risk population groups, such as prostitutes and truck drivers.
In Zambia the high prevalence areas, were, and have still remained, around the transport routes, the line of rail and border towns.
By 1990 it became clear that the epidemic had taken a hold in the general population and the key people at risk were married women. While the key source of infection , was their husbands.
Inspite of the focus on key prevention strategies the virus continued to spread. The virus took hold in Zambia the way fire takes hold of dry grass. When I worked as a newly graduated Doctor at the University Teaching Hospital, the Medical Admission ward had earned the name “Lebanon”.
It literally looked like a war zone, each night you were on call, people were being brought in, in advanced stages of the disease. In the middle of the 1990s some drugs which were effective in suppressing the virus became available. Initially at very high cost, but eventually through the lobbying of NGOs, the drugs became cheaper, and eventually become free under the public health sector. This brought some respite by allowing people to live longer and controlling the additional infections (opportunistic infection) which resulted from a lowered immunity. It is this which had made the disease fatal in earlier years.
2. Why has HIV thrived in Africa and in Zambia?
Many reason may be given why the HIV infection has remained persistently high. Some of these reasons include high levels of sexually transmitted infections, low condom use, traditional practices, Alcohol/drug abuse, multiple concurrent partnerships and low male circumcision rates.
In summary complacency. The initial strategies to control the disease by behavior changes had very minimal impact. Even if one examined the facts, you would find that the most high risk sexual behaviour occurs among educated men in the urban areas. The knowledge of HIV and HIV prevention methods have been shown to be high in Zambia.
Inspite of the high knowledge of HIV, most men consider themselves to have a low risk of acquiring HIV infection. The more educated a man is and the wealthier he is the less likely he is to perceive himself to be at risk of HIV.
Ironically the highest HIV prevalence and high risk sexual behaviour is most common among the highly educated, high income men, living in urban areas. They have the highest number of multiple concurrent partners (many girlfriends) and have low use of condoms. The HIV prevalence among employed educated men is two times higher than their unemployed counterparts.
The HIV prevalence peaks among men aged between 40-49 years. This is the time when the male hormones also begin to decline, so sexual function and performance begins to falter. However men are more established in their job at this time and have more disposable income. The result is that feeling of being financially invincible that makes them seek out more partners.
The economic and educational status gives them a false sense of accomplishment and makes them more complacent. They will also drink more heavily give out plenty of advice to their peers and are unlikely to use condoms. They will often be married but will also have young female partners (Sugar Daddy syndrome). They will have a high risk of HIV and are unlikely to be circumcised. Inspite of this they feel they are at low risk for HIV infection. We should accept that as educated middle aged men, we are the biggest driver of HIV in Zambia, and begin to do something about it.
3. What can I do to stem the tide of HIV?
One of the biggest problems which has fueled the spread of HIV is the false notion that makes me feel, that HIV affects others. The sense that it involves other groups in places very far from me. It is amazing to see how often even health workers are in denial about their HIV status.
I recall a health worker colleague of ours who had been an HIV counselor but refused himself to be tested for HIV. When it became clear that he was positive he refused to start treatment. Instead he started visiting witch doctors believing he had been bewitched. His main questions, was why me? So the first approach is to change our attitude of complacency, and accept that the disease can affect me as well.
We must also accept that those men who are wealthy, educated, in middle, and upper management positions are most at risk. They face the trappings created by their own success. In particular they attract the attention of vulnerable women. In this type of situation it is not unreasonable to be careful and take the following standard steps;
1.Be sober
2.Be circumcised
3. Be tested
It is clear that high alcohol intake is associated with high risk sexual behaviour. This is because it tends to suppress the natural timidity and replaces it with “Dutch courage” (false sense of courage).
So reducing the amount of alcohol you take, will certainly help keep you safe. Many studies have shown that male circumcision alongside with other safe sex practices will reduce the risk of HIV infection. Many men are reluctant to be circumcised in middle age.
This first because they mistakenly feel it is unsafe for older men, and secondly because they feel people will assume they are promiscuous. Both of which are incorrect perceptions. It is a good habit to go regularly for HIV testing. This gives you regular access to HIV services, counseling and early treatment, should you need it.