HIV/AIDS in Mali
By Dr. Geoff Dunkley

August 28, 2006

Hello All,

Karen has done more than her share of communicating and I thought maybe you should hear a bit from me first hand. Needless to say, life and work here is very challenging and rewarding and I am thankful for the experience. Some of what follows is based on a piece I wrote for a Citizen reporter. Excerpts were used in an editorial that appeared in the Ottawa Citizen as part of their coverage of the HIV/AIDS issue and the recent World AIDS Conference held in Toronto. (Based on feedback from some of you, I gathered our government’s participation and contribution was abysmal and I share your disappointment.)

I’ll start with a bit of a description of the region of Kayes where I am working. It is a region of 1.6 million people (approximately twice the population of Ottawa). It has one ‘large’ city, Kayes, with a population of about 70,000, which has electricity and water. There are two other smaller towns of 20 to 30,000 with electricity. For the rest, there are a few scattered generators.

It is completely dry for about eight months of the year with temperatures consistently in the forties. It rains about four months a year, the rains are torrential and roads become impassable for protracted periods even with four-wheel drive. Considerable areas of the region are inaccessible with minimal traffic in or out for that period. In one mountainous area, even in the dry season, access in many zones is impossible even by motorcycle or donkey cart and the only way to evacuate a woman in obstructed labour or other patients is four men carrying a hammock for ten to fifteen kilometres.

It has populations of herders and farmers sharing the same territory in uneasy tension. One of the key economic bases is remittance from émigrés in Europe.

Until about ten years ago, there was no road access to the region. The only access was by rail. A paved road from the capital is being built and is about two thirds finished. It will be completed next year.

For the health care system, (remember we are talking of a population double that of Ottawa’s) the region is divided into seven circles each with a population of 200,000 to 300,000. Each circle has a reference centre with two to five doctors where caesarean sections and basic general surgery can be done. Overall, including hospital staff, the region has one doctor for each 30,000 population, one nurse for each 10,500 population and one midwife for each 100,000 population. The region has one hospital with 200 beds and 19 doctors of whom eight are Cuban.

The government is trying mightily to give access to a basic package of services (PMA), preventive and curative through health centres at a distance of less than five kilometres from every member of the population (remember access is on foot or by donkey cart and we are talking sick people and mothers with tiny infants). The health centres serve approximately 20,000 people and generally have a staff of four to six of whom only one is usually professionally qualified, i.e. a doctor, nurse or midwife. There are still some centres with no professionally qualified staff. It is impossible to describe to you how isolated, understaffed these little centres are, and under what trying conditions their staff work. I have tremendous admiration for all who work there.

To date, the region of Kayes has achieved 38% of the population is within 5 km and 54% of the population is within 15 km of a health centre. This means that half the population has effectively no access to even the most basic curative services. There is outreach to non-covered areas to provide some preventive services such as immunization and prophylaxis for worm infestations.

I apologize for the rather long and detailed intro but I hope you will find it useful context. This is what colours my perspective on HIV/AIDS.

When facing up to the challenge of AIDS in Africa, it is useful to consider prevention and treatment separately. I’ll start with prevention.

Mali is a country with a number of traditional customs and practices that facilitate the spread of HIV: polygamy, sororat, lévirat (sorry, those are the French terms, I don’t have a big enough English dictionary to translate; essentially, if a man is widowed, he takes his wife’s younger sister in replacement; if a woman is widowed, she is married to her deceased husband’s younger brother; this has obvious consequences should the deceased partner have died of AIDS), early marriage for girls (mucous membranes more susceptible to infection), vanishingly low levels of contraception use (in fact, a woman even expressing a desire to use contraception just for childbirth spacing is likely to lead to divorce), high levels of sexually transmitted infections, widespread (98% in this region) male circumcision and excision (also known as female circumcision or genital mutilation) usually without sterile precautions, high use of traditional healers and childbirth attendants who also frequently do not use sterile precautions, and very low levels of education and literacy among women (about 30% are literate). Rates of voluntary testing are very low due both to a basic resistance of the population and a lack of reagents and testing sites.

Despite this the rates of HIV in Mali and indeed, in West Africa generally, are much lower than the terrifying rates of spread seen in Southern and Eastern Africa. The reasons for this are unclear but probably due, at least in part, to higher levels of male circumcision and lower rates of certain ulcerative STI’s such as syphilis, herpes and chancroid.

It’s always easier to describe a problem than to propose a solution. Mali has a number of practices favouring the spread of HIV, which are foreign (and probably unacceptable) to most Canadians. They are also deeply ingrained in a conservative, patriarchal and highly religious society. How do you make people understand the health impacts of these practices? Will they change these practices if they do understand the potential health impacts? Particularly for women, do they have any control even if they do understand?

Because of its lethality and its transmission via sex and blood, AIDS has tended to force society to face things about itself that it would be more comfortable ignoring. This is as true in Africa as in Canada, but, as in Canada, that facing up is arduous and painful and long.

For all our educational programs in Canada, we have still high rates of injection drug use with needle sharing, unprotected sex and people failing to disclose their status to their partner. Protection of the blood supply is probably our only clear victory in the prevention of HIV/AIDS. It is my belief that our educational programs targeting behaviour change have limited impact because as a society we fail to address the issues that underlie these behaviours.

For instance, Canada continues to criminalize drug use and prostitution despite overwhelming evidence that the criminalization is vastly more destructive to both the victims and society as a whole than the problems it is purporting to prevent. It is also almost completely ineffective in reducing either drug use or prostitution. (Others explain this much better than I can.) To put it another way, the health impacts of drug use and prostitution have not been sufficient to persuade Canadian society to date, to change its policy in these areas.

We also continue to have all kinds of hang-ups about sexuality though I do believe we are making some progress.

The point I would like to make is that Canadians and Canadian governments have a number of cultural blind spots that make AIDS difficult if not impossible to control in the short term. This is true despite a relatively educated and literate population, a vast communication infrastructure, and governments with extensive research and policy-making resources. It is much more difficult to be effective in Africa which has none of these things.

During discussions with colleagues here, I describe some of our beliefs and customs in Canada: gay marriage, equal rights for women, couples choosing to remain childless, mothers of young children working while their children are in daycare. I see them react with the same sort of disbelief and horror that I feel for the practice of excision. An African or a Canadian looking at their list of behaviours that facilitate the spread of HIV can ask themselves a series of questions. Which are the moral absolutes? Which are essential attributes of our culture? Which reflect one group asserting its power over another? Which are simply matters of convenience and choice?

Each society must find its own slow and difficult way through the conflicting answers to these questions. A society may decide a practice exploitative of one group in society over another to be an essential attribute of their culture. There may be profound differences over which are moral absolutes (see the Canadian debate over abortion). There will be learned debates and difficult policy decisions but ultimately, the result will depend on each individual’s behaviour based on their knowledge, acculturation, resources and decision-making. Societal sanctions may make little difference (See drug use, abortion and prostitution in North America) It is, (from my perspective) unfortunate but true that the health impact on AIDS and other diseases may not be the deciding factor in the debate at either the governmental or the individual level. For my two cents, the most hopeful road for Africa is universal education for girls and women and the difficult path to full equality between the sexes, which I do believe is a moral absolute. I do fear that Africa may not have the time or the will to travel that road.

Which brings me to treatment.

Millions of people in Africa are infected with AIDS and will die if they do not receive antiretroviral treatment. The urgency of this cannot be overstated, but the difficulties should not be underplayed.

In Mali and in much of Africa, malaria, the death of mothers and babies during childbirth, diarrhoeal illnesses, and simple pneumonias each kill millions of women and children. The solutions and treatments are well known and inexpensive and yet the efforts to date, including large amounts of aid and technical assistance and brilliant innovations such as Integrated Management of Childhood Illness (IMCI) have had only marginal impacts on these problems. The problem is that these countries lack a delivery system particularly in their rural and isolated areas. The region of Kayes, described above is a not atypical example.

The technical, logistical and human resource challenges of delivering lifelong antiretroviral treatment to millions of people given the infrastructure currently in place are literally overwhelming. In Eastern and Southern Africa the number of health care workers who are already infected and need treatment themselves compounds the problem.

In Kayes, antiretroviral treatment is available only in the one hospital. They are struggling to get treatment of maternal infant transmission available in one site in each of the seven circles. What is needed is a full complement of health centres, so each person has access within 5 km. Each health centre needs to offer HIV testing as well as the maintenance of antiretroviral treatment, with appropriate testing modalities available and clear referral protocols. This service should not displace other services such as pregnancy care, vaccination and treatment of childhood illness. Transportation and infrastructure issues such as electricity, water and an effective laboratory must be solved. Finally, the people must be persuaded to be tested and to be treated.

In other words, the treatment of HIV/AIDS must be integrated into the existing delivery system. To do this effectively will require an enormous qualitative leap in the capacity and the resources of the system. Any other course is, to my mind, folly. To create any kind of parallel or special system would be inefficient, would suck resources and personnel away form the existing system, and, unless it was restricted to the larger cities where the underlying infrastructure was already in place, would founder on exactly the same issues as the existing system.

Building a health care system which is capable of delivering HIV testing and AIDS treatment to the whole population will require an enormous investment but it will also require time; time to build the infrastructure, time to train the personnel. It is time that those millions of people currently infected do not have. So shortcuts will have to be taken. Difficult decisions will have to be made. I will again add two cents:

• Invest in the existing system, don’t create a parallel one.
• Don’t compromise or distort existing preventive and curative services for women and children, in fact use this initiative to strengthen them.
• Prioritize testing and treatments for health care workers and teachers.
• Don’t forget the people in the rural areas.
• After trained personnel, the lack of a transportation infrastructure is the biggest obstacle to success.
• Don’t sacrifice the long-term development of each country and its health care system to the exigencies of the current crisis.
• The world must do more. Africa must do more. Canada most particularly must do more.

It is somewhat cathartic to have expressed myself. Because my role here is to advise and support, I find I don’t often get to say what I am really thinking. Thank you for this venue.

Karen is about to launch a project teaching patchwork to young women with little or no education. She has bumped into 3 Sisters and an empty classroom with 6 sewing machines at the Catholic Mission. She also noticed that many of the tailors here (and there are many because few clothes are sold ready made) toss fabric scraps. Karen, the quilter, could not let this continue! Hopefully, in a few months some of the women will be making products for sale to tourists and business folk who come to Kayes and Bamako. This is being done on a very thin shoestring thanks to our own funds, help from some of you, and the Unitarian Fellowship of Ottawa.

She is also helping our cook, Therese, prepare a business plan and gather money so Therese can achieve her dream of opening a restaurant. We may lose Therese but gain a place to have a decent meal out now and then, something virtually non-existent here.

Karen and I are looking forward to a short trip home in mid-October. One of my Malian colleagues and I are presenting at the Canadian Society for International Health conference in Ottawa. It will good to run along the canal, have a turkey dinner, hug family, and see those of you we can squeeze into the brief visit. Life here is good but Dorothy was right, “There’s no place like home.”

All the best,

Dr. Geoff Dunkley (and Karen too)