By Jena Ardell
By Jon Campbell
By Alan Scherstuhl
By Tessa Stuart
By Roy Edroso
By Jon Campbell
By Albert Samaha
By Zachary D. Roberts
As Africans struggle to sort out their agonizing treatment prioritiesfood? clean water? basic medicines?they must also cope with the emotions that arise with an endless tide of deaths that they now know are preventable. "It was easier when there was nothing at all to treat HIV," says Lillian Mworeko, an HIV-positive school teacher and member of NGEN+. "Now there is something, so it's like seeing food when you're starving, but you can't eat."
ELLY KATABIRA COPES BY BLOCKING OUT everything except "that patient sitting in front of me." Katabira founded the AIDS clinic at Uganda's flagship Mulago Hospital in Kampala and co-wrote Africa's first manual on HIV care. In that book, he laid out his philosophy: "Use what you have."
Through extensive research and observation, Katabira and his colleagues have tweaked medical care. Thrusha painful fungal infection of the mouth and throatafflicts virtually every HIV patient, making it hard to eat because of the pain of swallowing. The cheapest treatment is nystatin; Ugandan doctors found that sucking the tablets rather than swallowing them gets more of the drug absorbed into the tissues of the mouth, making it more effective. Skin rashes are also extremely common among HIV patients. "There was a tendency to look at the skin alone," Katabira says. But if the rash is bad, he prescribes a sedative. "It allows the patient to relax and sleep, so he's refreshed and able to make himself active, which in turn means he's less likely to scratch."
"What I think is most important," he continues, "is supportcounseling and reassurance that, yes, you are sick, but there are a lot of things you can do to improve your living without medicine. Simple things, like reducing your alcohol intake and going to the doctor as soon as you feel sick. And dealing with dependents. A parent will never get better if she's worried about her children. These things are considered second-rate, but I think they're very important."
The ultimate proof: "Our patients are living longer. I'm proud of that. Without protease inhibitors, they are living longer."
Yet the hard reality is that without such advanced drugs, the virus keeps replicating, slowly destroying the immune system. Almost all the infections that result can be treatedin rich countries. But in Uganda, says Katabira, "if you get CMV [a viral infection that blinds and kills], that's the end of the story. The drugs are just too expensive." Same for cryptococcal meningitis. What's more, CMV and the main AIDS pneumonia PCP are both preventablebut not with Third World budgets. The painful genital sores of herpes simplex, which most Ugandan HIV patients get, are easily controlled with acyclovir, but Katabira reckons that "less than 1 percent of my patients can afford it."
"Many people think that because I'm in the field of AIDS, I look at it as something special. No," Katabira says. "The problem is wider. I go to the pediatric ward, and kids are dying because there's no amoxicillin," a basic antibiotic. "I could have walked away in protest, but I must do each and every thing possible to get my patient through the next day. Use what you have."
PATRICK OKELLO, A TALL HIV-POSITIVE patient living in Lira, has the mango tree. He boils its roots, which helps him fight diarrhea. Many people go to traditional healers to get herbal remedies. Indeed, up to 85 percent of Africans consult healers, not surprising given that they are far more plentiful than physicians and that they hold an esteemed position in most African cultures.
Western doctors have tended to dismiss their efforts. But in Uganda, some of the first evidence emerged that herbal remedies can effectively treat AIDS-related illnesses. A study of patients with chronic diarrhea or herpes zoster found that those treated by traditional healers fared slightly better than those given Western medicines. Studies in Zimbabwe and Senegal have confirmed that some traditional treatments work against some illnesses, especially diarrhea. And healers can make a patient feel cared for, an important psychological boost.
Unfortunately, there is no way to tell who is a charlatan, or even which remedies given by a well-meaning healer are truly effective. Awany, the woman who wishes she had shoes to protect against rashes and boils, went to a traditional healer for diarrhea; the herbs he gave her only worsened the problem. "When I told him it didn't work, he said it was washing out the stomach to wash away the germs. I was almost at the dying point when I went to the hospital." But over in the next town, Rose Aciro swears by the thrush treatment she gets from her healer.
Most Ugandan healers claim to alleviate opportunistic illnesses, but only a few profess to cure AIDS itself. Not even antiretrovirals can do that, but they do keep the virus in check, which is why David wants them. This January, the trim, articulate partner in an advertising and media firm, who asked that his real name not be used, started triple combination therapy through the UNAIDS program. Including all the laboratory tests, the treatment costs him between 8 and 9 million Ugandan shillings a year, or about 6250 U.S. dollars. That would have been bearable last year, when his company landed a one-time windfall contract and David took home about 20 million shillings, or $14,000. But this year, he says, "I won't make half of that."