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Contributions from
the Column
Focus
Fragmented goals
E“We do not sit down and wait for assistance”
Squaring
the accountability triangle
“We need coherent national strategies”
Drugs are not enough
8-9/2005
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“We do not sit
down and wait for assistance”
According to government estimates, seven percent of Tanzania’s adult population is infected with HIV/AIDS. The pandemic is challenging the authorities on several fronts. On the one hand, preventing the disease requires behavioural changes including the acceptance of condoms. On the other hand, the health sector needs to be beefed up in order to be able to take care of the patients. Herman C. Lupogo, the head of TACAIDS, the Tanzania Commission for AIDS, discussed these issues with D+C/E+Z.
[ Interview with Herman C. Lupogo ]
Will Tanzania succeed in reducing the prevalence of AIDS in the next ten years?
Well, one of the aspects of my business is to be optimistic. And definitely I am very confident that we will make a big dent in the epidemic in the next ten years. I am saying it because of the way that the people in the towns and also in the countryside take up the idea of fighting AIDS. It is not going to be in vain, we certainly are going to reduce the rate of infection.
Are people in Tanzania aware of the dimension of this catastrophy?
Yes, they are very much aware of it, because of the sicknesses and the deaths, which are taking place in every village. I know of a small locality that witnessed eight funerals just because of AIDS in one week. The trouble, however, is that we have people who are superstitious and still think that sickness is caused by witchcraft. They are the minority, but they are there. Another problem is that many people from urban areas return to their villages when they get sick or when they realise that they have been infected. They die there – but sometimes infect a few other people before. The villages therefore bear the brunt of the urban pandemic as well as of the local infections. People are certainly aware of the problem.
Does the international debate on the Millennium Development Goals help you in your fight against HIV/AIDS?
I’m afraid the Millennium Debate does not help us much. But the actions which follow from the debate do. In other words, if the MDG agenda means an increase in the support that we get and we use it properly – and I know that we will – our people will become better educated with respect to the disease but also to health issues in general. Similarly, our country needs to learn more about economic development, increasing production, understanding the world and raising our standard of living. If, for instance, we manage to keep the environment cleaner, then it means the overall quality of life is going up. And if the quality of life goes up, it will also reduce the instance of HIV infection.
But educated people are also affected by HIV/AIDS.
Indeed, a recent survey of ours has shown that infection rates tend to be high among better educated people. That raises the question whether staying in school longer means becoming better educated or merely learning how to read and write better. If the education that comes along with the fulfilment of the Millennium Goals means understanding ourselves better, we will escape HIV.
Are donors doing what they should? Tanzania is a country that many donors support – and their assessment of your government is very favourable.
I find it very difficult to say whether or not donors are doing what they should. However, what we are doing is set out our plans and programmes and ask donors to join in and assist us – and they are doing that to a very large extent. In fact, fewer and fewer donors are doing as they please. Instead, they are coming to us and asking what is it that we want to have done, and they assist us on that. We have convinced them that our official policy, which was launched in November 2001, makes sense. The focus is on prevention, care and treatment, voluntary counselling and testing and impact assessment.
How is the goal of reducing the incidents of AIDS related to other MDGs such as reducing child mortality, maternal mortality or hunger?
If you beef up the health service, it means that you will take better care of children, that you will take better care of mothers with the children, you will take better care of malaria patients and so on, and therefore two things will happen: fewer deaths because of these diseases and if there are fewer deaths that means there will be fewer orphans. And so with the increased perception, with the increased education it means that HIV/AIDS prevention will also be assisted by the other Millennium Development Goals. HIV/AIDS in itself, however, is a terrible burden on our country – and on mankind in general.
Dealing with maternal mortality has a lot to do with the female body and empowering women to take care of themselves. How does the HIV/AIDS issue come into the picture?
HIV/AIDS disturbs the process. Women are reluctant to take the tests and find out whether they are positive or not. Infected pregnant women, for instance, face great problems. The chances are about 30 to 40 percent that they are going to infect their children. And they are likely to die early, leaving behind sickly orphans. If our preventive measures are successful, we will reduce that aspect. But for that to succeed we need better medical interventions including the use of anti-retroviral pharmaceuticals (ARVs). All these issues are interrelated and we can’t look at HIV/AIDS as a separate issue. You see, a lot AIDS cases also go along with tuberculosis or malaria. And sick parents cannot provide for their children – they may even find it difficult to feed them.
Anti-retroviral medication is expensive. As a rule of thumb, these pills cost a dollar per patient and day – even if relatively cheap generic drugs are used. That would add up to 365 dollars per patient and year. Tanzania’s annual per capita income is only 290 dollars.
That is why the government has decided that we are going to give the patients ARVs free of cost.
You need donor support, or else you cannot afford that.
We are using our own funds too. When we started working with ARVs, the treasury gave us two million dollars to buy the initial drugs. That was a government expenditure. What usually happens if we ourselves are ready to spend something on a particular intervention is that it becomes easier for any donor to see that we are serious and assist us. We do not sit down and wait for assistance, we act to prove that we deserve assistance.
Who funds the ARV programme?
Our health sector relies on support from the entire donor community. As for ARVs, the Global Fund, the World Bank, Canada and Scandinavian countries as well as the Gates Foundation and the Clinton Foundation are helping us. But it all depends on the programmes we draft. Our plan is to treat up to 400.000 people with ARVs in the next five years and we want to live up to that commitment. Donors have shown a lot of flexibility in cooperation with us.
So you do not see financing as the main problem – even though some experts estimate that procuring generics for 400.000 patients will cost as much as Tanzania’s total health budget can afford in 2005.
Financing may be difficult, but we are confident that between our own local resources and the assistance that has been promised to us we’ll be able to make it. Some other challenges are at least as daunting: training enough health workers to do the diagnostic and supportive work for the patients. This is an up-hill struggle, but we intend to win.
Perhaps the greatest challenge is prevention, actually changing behaviour. That is hard to change anywhere in the world. To some extent, the homosexual communities of western countries actually did change their behaviour by accepting the use of condoms. Do you see indicators something like that happening in Tanzania?
I can see that change coming on, because we now realise that we do not import enough condoms. And the demand for condoms is very great both in the urban centres and in the countryside, which is an indication that people are aware of how to prevent the spread of HIV. Five years ago, people did not speak of AIDS, but today some 90 percent know how the disease is spread.
So the use of condoms is no longer taboo?
It is not taboo.
But it was?
It wasn’t. I remember seeing condoms in the fifties, but they were used for birth control. Some people also used them to prevent the spread of sexually transmitted diseases such as syphilis. But now HIV has come in, the condoms have gone up in currency, they are now much more in demand than they used to be.
Your country is a multicultural country with more than 120 different ethnic traditions. That multitude should make it much more difficult to reach a shared view on sexual behaviour. It is probably easier to deal with the urban communities than the rural ones.
We are aware of the problem and have decided to go forward by engaging local government authorities. Everybody, whether in urban or rural areas, lives under the jurisdiction of some local government authority. These authorities are best placed to serve the communities in their areas. If an authority is located in the countryside, it is going to be very much tribal because that is were the tribes live. In urban areas, the attitudes are more cosmopolitan. It is easier for local authorities to deal with their communities because their staff normally belongs to the same communities. They understand – and the local people are more likely to listen to them than to a stranger from far away. Decentralisation to the local government authorities is going to make an impact.
Speaking of various traditions and values – the Catholic Church opposes the use of condoms. What is your standpoint?
It is quite obvious that the Catholic Church is right in saying that there should be no sex outside the wedlock. That is the moral stand, but it is unfortunately also idealistic. In practice, I know that very many people, Catholics and people of other persuasions, are engaging in sex outside of marriage. And what we are saying here in Tanzania is that if they are going to engage in illicit sex then they might as well use condoms, so they do not get infected. The ideal is: no to condoms. But reality says: please use them, if you are sinning.
Questions by Hans Dembowski.
Herman C. Lupogo
is a retired General. He was appointed Executive Chairman
of the Tanzania Commission for AIDS in December 2000.
hlupogo@yahoo.com
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