Saturday is for funerals

  • Unity Dow &
  • Max Essex
Harvard University Press, 2010 240 pp., hardcover, $19.95 0674050770 | ISBN: 0-674-05077-0

More than 300,000 people in Botswana, around 25% of the entire adult population, were estimated to be living with HIV/AIDS in 2007, a staggering prevalence second only to that in the tiny kingdom of Swaziland. A few years earlier, the Botswana president, Festus Mogae, had described the situation in his country as follows: “we are threatened with extinction. People are dying in chillingly high numbers. It is a crisis of the first magnitude.”

Funerals, which in Botswana are traditionally held on a Saturday, were taking up every weekend, making it impossible to squeeze in happier events such as weddings. Friends and relatives had become weary of the weekly calendar of grieving. How can you convey the devastating impact on ordinary people of a deadly infection on this scale? What is it like to live in a country where one in four of your friends, family, colleagues and neighbors is infected with a virus that, without treatment, will inevitably lead to disease and death? In the West, most people have never experienced the fear and anguish of an infectious disease epidemic that can indiscriminately scythe through the people close to us, although such epidemics were commonplace just a few generations ago. Similarly, although the prevalence of HIV-1 infection continues to increase steadily throughout the developed world, for most Westerners it will not reach the stage when the impact of HIV is felt in all aspects of everyday life, especially given that the widespread availability of effective antiretroviral therapy (ART) means that HIV-1 infection has become a chronic disease that is effectively compatible with normal life.

Unity Dow is an acclaimed author and human rights activist who was the first woman judge to be appointed to the High Court in Botswana. Max Essex is a medical researcher from the Harvard School of Public Health who has studied HIV-1 infection since the beginning of the epidemic; in 1996 he was invited by the president of Botswana to be an advisor on the HIV situation in the country, leading to the establishment of the flourishing Botswana-Harvard partnership for HIV research and treatment. Together, Dow and Essex bring their distinct and complementary knowledge of HIV infection in southern Africa into a book that effectively depicts both the personal and the scientific facets of the Botswana AIDS epidemic. Each chapter vividly describes a personal account of HIV infection that Judge Dow encountered during the height of the epidemic, followed by a straightforward and accurate account of the relevant aspects of HIV biology and treatment, covering a range of issues including mother-to-child transmission, male circumcision, HIV vaccine development and the role of traditional medicine. The science is competently explained in terms that a lay person could understand, and the combination works well, making this book a good introduction to the key facts about HIV/AIDS as well as a moving depiction of the individual tragedies this disease can inflict. In the context of a real person's story, the science seems more relevant and less dry. This book would be worthwhile reading for people who want to learn more about the HIV epidemic but would never pick up a textbook or scientific article.

Although many of the cases are deeply tragic, the book has an optimistic note. The government in Botswana has for many years been resolute in its determination to tackle the AIDS epidemic. Indeed, President Mogae made a commitment early in his presidency never to give a speech in Botswana that did not mention AIDS. Botswana was the first African country to introduce a national program for ART along with 'opt-out' HIV testing, in which blood samples collected in the course of routine clinical care are tested for HIV unless the person specifically refuses the test. In most other countries, HIV testing is offered in particular settings, such as clinics for tuberculosis or sexually transmitted diseases or to pregnant women, but many people who are less obviously at risk of being infected with HIV never get tested and therefore cannot seek appropriate medical treatment. As a consequence of these policies, Botswana has the highest proportion anywhere in Africa of HIV-positive people needing ART who are now taking effective treatment, leading to a generally healthier population and substantially fewer new cases of HIV infection. This is amply illustrated in one of the chapters of this book, in the apparently paradoxical response of “Mandla,” a colleague of Judge Dow's, to the news that he has HIV. Mandla was getting sicker and sicker but was terrified of having an HIV test. After he was finally persuaded to get tested, he told the judge “just knowing is such a burden from my shoulders. Now I can start treatment.” Although the story of HIV in Botswana is far from over, Saturday is now no longer just for funerals.

It is not explicitly discussed in the book, but the determination and pragmatic approach of the Botswana government is in stark contrast to the attitude of denial adopted by many other African governments (past and present) toward their own HIV epidemics. The reluctance of the previous government in South Africa to acknowledge the scale of their HIV epidemic and to embrace a national ART program is well known, but leaders of other countries have also been guilty of attempting to minimize the problem. In my view, this book should be compulsory reading for policy makers and leaders throughout Africa, who often appear to be unaccountably remote from the suffering of ordinary people in their countries.