TURNING THE TIDE TOGETHER

XIX International AIDS Conference

With over 20,000 other participants, Marjorie, Chrisie and Ida gathered in Washington at the XIX International AIDS Conference, for a series of meetings, speeches and other sessions which told of the challenges and successes, the questions and responses in both the lab and in the field. We should be proud that the Church of Scotland, as part of its Mission, has a programme that focuses on HIV prevention, that is working to end discrimination against HIV patients, and that advocates research and investment to make treatment available to all those who need it.

Sunday 22 & Monday 23 July 2012

The M&E Session before the opening was useful in showcasing a solar powered laptop, used for collecting and processing data in remote rural areas.

At the opening, we learned that Zambia’s infection rate has decreased and that more people are able to access ARVs than previously. These are new infections being treated and we are not just treating those waiting in the queue. Proper adherence should ensure people living with HIV can enjoy a more normal, fulfilling and longer quality of life.

Treatment is a form of prevention. This is especially true in the case of PMTCT. If all HIV+ mothers receive ARVs, then the risk of transmission to the child is minimal. Malawi has already gone down this road with good results (Option B+). Zambia is being encouraged by WHO to follow suit. In doing this, the 2015 goal mentioned at the faith-based conference should be reached.

Related to this, is the necessity to upscale our outreach to youth. Too many do not know their status, this is not helped by their exclusion from adult programmes. That is why, at Mwandi, our provision of a Youth-Friendly Corner (and the appointment of a Youth Co-ordinator) has been so important. It will continue to provide quality care, education, testing and easy access to ARVs, for this important segment of the population in the catchment area. Only through this, can stigma be addressed and help offered by peer educators.

The Food Security Session showed how hospitals can work closely with nutritionists to improve the diet of patients. The Nutrition Department prescribe donated food to patients based on their BMI.

However, a significant challenge to be faced is ‘leakage’, ie. the numbers tested and found positive amongst babies, children, youth and adults are far greater than those who actually commence treatment.

On the Sunday afternoon, a large crowd gathered near the Washington Monument as part of the Washington ‘Keep the Promise’ March. Andrew Young and Rev Al Sharpton gave inspiring speeches, setting the stage for some further introspection.

It was also good to see the AIDS Memorial Quilt, that was started by gay rights activists who wanted to make certain that their friends who had died of AIDS would not be forgotten. The quilt is now the largest community art project in the world, and is a poignant testimony to love, peace, and hope.  There are men, women and children from every continent, remembered in the panels. It is a wonderful and moving memorial to those who have died, but also a celebration of life.

Tuesday 24 July 2012

Hilary Clinton addressed the plenary session on Tuesday. The first item after that was entitled ‘Science to Public Health’, and discussed the tools necessary to end the epidemic. An AIDS-free generation was the ultimate goal. There was a moral responsibility to ensure this.

Tuesday also saw the opening of the Global Village, which is the focal point for science, medicine, civil society and the wider community. It is a noisy, vibrant and colourful area, with an eclectic array of fringe events and activities.

In the afternoon, an interesting session took place, on the critical and growing role of the faith community in treatment and advocacy, to increase the political will to fight AIDS locally, nationally and internationally. Access, dignity and inclusion are all part of our work for justice. Other meetings Ida attended dealt with developing community support and capacity, remuneration for Home-Based Care workers, and finally Prevention, which brought Tuesday to a close.

Wednesday 25 July

The Wednesday Plenary opened with research on the HIV vaccine and highlighted the effect of the epidemic on children, adolescents and women in particular. Women account for over half the 34 million people living with HIV worldwide, and the rate of infection is twice the male rate in Sub-Saharan Africa.

Ida spent a lot of time learning about finances and the efficient use of funding. She listened to DFID and Global Fund discuss the effect the present financial crisis was having on funding. Other areas of interest were scaling up PMTCT, and learning about the demand and supply side of pharmaceuticals. Ida was honoured to be able to speak about how policy-makers' decisions, and their implementation, affect people at the grassroots level.

Thursday 26 July

The plenary dealt with the dynamics of the epidemic, in particular, contexts with groups most vulnerable to infection, including sex-workers. Expanding testing and treatment, while at the same time ensuring greater adherence and prevention, were some of the approaches suggested. The Global Fund held more public sessions on:  political commitment, resources and pricing; a sub-Saharan session on the cancellation of Round 11 grants, and finally a meeting called "The Next Five Years", which outlined the strategic direction and future hopes.

Friday 27 July

The final day’s plenary was concerned with co-infections, including TB and other non-communicable diseases, such as heart disease, cancer and diabetes. We heard that the cost of treating a patient in Zambia is $200 per year. The closing session was addressed by a series of politicians and international worthies, and ended with a keynote address by Bill Clinton.

The XX International AIDS Conference (AIDS 2014) will convene in Melbourne 20-25 July 2014.

One especially memorable highlight for Ida was greeting Kenneth Kaunda on the escalator. He was going down as Ida was going up. We don’t know who was more surprised - Ida, seeing the First President, or Kenneth, being greeted by Ida so far away from home, in a Washington DC Conference Centre in the Lozi manner (Kukandalela)!


Ida Waddell and Marjorie Clark

Thanks to the Church of Scotland for their financial and logistical help to make attendance at this conference possible for Ida. Thanks, too, to her old friend, Megan. It was a good time of spiritual, personal and professional development. It was useful and enjoyable spending time with colleagues, and also meeting and speaking with other people from the diverse communities involved in the fight against the epidemic – science, advocacy, faith, politicians and vulnerable populations.

Two David and Goliath Struggles

Our Aids Relief Programme here at Mwandi has over 1500 people alive today thanks to affordable supplies of ARVs (antiretroviral drugs) from India. The cost of these drugs has fallen from around GBP200 a year to about GBP45 – thanks to the Indian generic drugs industry. This means that international donors, including ironically, the EU’s Global Funding, can help at least six million HIV-positive mostly people in the less-developed world.

Our programme also relies on generic medicines from India to treat other diseases and conditions. But a free trade agreement, currently under negotiation between the EU and India, could greatly restrict the ability of manufacturers in India to continue producing affordable generics that millions of people rely on to stay alive.

At the moment European Union is having trade talks with India and want to increase protection of the intellectual property rights and the commercial interests of European pharmaceuticals giants. They call it "data exclusivity" and along with this the EU is proposing an ambitious enforcement agenda. These harmful intellectual property (IP) provisions will hinder access to quality and affordable generic medicines produced in India, which have played a crucial role in scaling up HIV treatment to more than 6.6 million people across Asia, Africa and Latin America.

The Indian government has raised serious concerns, stating that the agreement could ‘impede legitimate competition and shift the costs of enforcing private commercial rights to governments, consumers and taxpayers’. The European Commission is also apparently pushing for the trade deal to be expanded to cover investments, and not only intellectual property but also an ‘investor-to-state’ mechanism.

This would allow multinational drug companies to bypass Indian courts and take the Indian government to private arbitration courts in investment disputes over intellectual property, which could also lead to the reverse of domestic health policies like tobacco warnings and measures to reduce prices of medicines

The EC are also trying to persuade India to accept restrictions on its generic medicine industry that would mean delays of up to 10 years in producing generic versions of any new, improved medicines and up to 15 years in the case of children’s versions of the same drugs. This is clearly an attack on the health of the world's poor motivated by the callous demands of profit-hungry multinational pharmaceutical companies.

It is vital that this is brought to light and stopped. The rights of people living with HIV having easy and affordable access to essential and life-saving medicine must be protected, especially for the world's most impoverished and vulnerable people.

Greed should not triumph over need.

Yesterday our Chipolopolo Boys, the Copper Bullets, aka Zambia’s National Football Team arrived back home from Libreville, Gabon, to an ecstatic welcome in Lusaka where an estimated 200 000 people thronged the streets all the way from the Airport to the Showgrounds. Winning the African Cup of Nations was something to really celebrate with pride nationwide. People all over the country, including Mwandi, wore football tops, clothes or chitenges in the national colours of green, red, orange and black. Zambia won the African Nations Cup for the first time on Sunday, beating the favourites, the Ivory Coast, 8-7 in a penalty shootout after a goalless draw in the final.

Zambia had been seen as the underdog and had to put up with all the usual patronizing and condescension from the World Soccer Establishment’s pundits at the competition. The Zambian team was considered second-rate, rank outsiders and potential also-rans. So the victory brought some joy and consolation too to this Zam-Scot after our own recent tennis, soccer and rugby disappointments.

The team had earlier paid a moving visit to the beach to commemorate the loss of the 1993 Zambian football team in a plane crash outside Libreville in Gabon where they were to play. That Zambian team was expected to win the game and qualify for the 1994 World Cup but the entire team was wiped out, except for Kalusha Bwalya, now the President of the Zambian FA. So the match on Sunday was a “Date with Destiny”.

The competition comprises of 54 teams and en route to the Championship Final Zambia eliminated Senegal, Equatorial Guinea and Ghana.

The presentation of the cup was a national occasion, to receive it were First Republican President Kenneth Kaunda, Rupiah Banda the former President, the present Vice-President Guy Scott, Kalusha Bwalya and Christopher Katongo, the Captain.

Ivory Coast (Orange): Barry; Gosso, K Toure, Bamba, Tiene; Zokora, Y Toure, Tiote; Gervinho, Drogba, Kalou.

Zambia (Green): Mweene; Nkausu, Sunzu, Himoonde, Musonda; Chansa, Lungu, Sinkala, Kalab; C Katonga, Mayuka, F Katongo.

The cost of a free education

While most of us in the more developed world take universal, free and compulsory primary and secondary education for granted, this is far from being the case in Zambia. This week we heard that the Government has plans to abolish all fees in schools but is hindered by the amount of public money needed to purchase maize through the Food Reserve Agency. After this is achieved, it intends to concentrate spending on education and health to improve peoples’ lives. This will not be possible either, unless, as Kenneth Kaunda pointed out recently, the mining companies raise output and pay their due taxes without equivocation or attempts at avoidance or evasion. Doing this would be a good use of their investment to help grow the economy so that ordinary citizens and their families benefit.

The Government and previous ones were committed to providing free education from Grade 1 to Grade 12, as part of the 2015 Millennium Goals. Goal Number 2 is the provision of universal primary education. To this end the Government has announced the phasing out of the Basic (G1-9) & High School (G10-12) and a return to Primary (G1-7) and Secondary Schools (G8-12). We are still unsure of the timescale for this. Cynics say this makes Goal 2 much easier to achieve. The Government is concerned that learning achievement in the present system is low.

Our High School at Mwandi has been allocated 2 Grade 10 classes this year. Nationwide, 124 333 out of 276 840 pupils will be given Grade 10 places. This is almost 45%. 68 000 boys and 56 000 girls! Not yet gender parity there! 145 000 passed in 6 or more subjects. This is 52%, up from 49% last year. There were 30 000 no shows and 20 000 failed in all subjects.

Related to all this the Jesuit Centre for Theological Reflection has recently published a paper ‘How free is free education?’ www.jctr.org.zm

We have little Ellie staying with us during term time this year. We have known Ellie since she was born. She was born with a club foot and had to have her right knee amputated then. She goes regularly to the Italian Orthopedic Hospital in Lusaka to have her prosthesis adjusted. She started Primary 1 in January this year. Her family lives and farms between Mabumbu and Sankalonga but Ellie cannot walk the 10km to school, hence her boarding with us during term-time, so we do have some insight into the costs incurred by Zambian families with school children.

In 2002 user-fees were abolished in Primary Schools, this was a welcomed reversal of IMF/World Bank ‘cost-sharing’ conditions in the Structural Adjustment Plan which had to be accepted to gain debt relief. These fees actually did very little to improve or expand education in Zambia. Then the Mwanawasa Government promised free education to Grade 12 and that no child should be prevented from receiving education because of fees.

The paper makes a distinction between direct and indirect costs. Education will never be entirely free and indirect costs can restrict the availability of education to poorer children as much as direct costs. There are still direct fees charged at Primary School through the PTA Levy and also Project Fees can be levied. These can range from K10 000-K30 000 per year. The indirect costs are school uniforms, shoes, textbooks, stationery supplies, transportation, ‘tuition fees’ and food for breaks and lunch. This can easily come to over K400 000 for one child.

Between 2000 and 2004 primary school attendance rose from 71-85%. This still leaves at least 15% or 300 000 children aged 7-13 not attending school who should be there. It is suggested that it is a lack of money that keeps these children away. Also it is girls who suffer most in these circumstances. Bursaries need to be more accessible and available to help the more vulnerable to attend school. In the 21st Century we need to ask ourselves is it right that a child is sent home because they have no uniform or shoes or are unable to pay the fees? Is Zambia really that poor? If we are serious about this then there needs to be higher grants going to schools that serve poorer areas for recurrent costs and rehabilitation. Our Basic School received a meagre K3m last year for 1500 pupils

In many places public education is close to collapse with over-enrolment, straitened resources, decaying infrastructure and a demoralized work-force. The 1:70 teacher to pupil ratio has remained unchanged for 10 years. The shortage of textbooks is chronic. 1 book to 4 pupils is an exceptional ratio and in many subject the teacher has the sole textbook for that class in that subject. State school teachers earn from K1m per month ($200) to around K2.5m ($500) for a Headteacher. In Grades 8 & 9, not being “Primary”, pupils are often charged around K300 000. The cost at Mwandi is K90 000.

High Schools like Sesheke will cost K1.2m per year. Our High School charges K750 000.

Vulnerable families and the schools in Mwandi have benefited greatly from the Mwandi UCZ OVC Programme that sponsors around 500 pupils at the Basic School and 90 out of 220 at the High School. The programme feeds 200 pupils daily. There is another program that helps with direct costs for children from poorer families within and outwith Mwandi with an emphasis on educational assistance for the girl child. It has put 24 pupils through Sesheke High School between 2007-11 and has helped 9 pupils in Grades 10 & 11 at Mwandi High School and others Basic Schools. We are indebted to many individuals and congregations who through their generosity make it possible to educate needy children by helping to meeting the direct and indirect costs which their families otherwise would struggle to afford.

There is an old truism, if you think education is expensive try ignorance and that there are some people who know the cost of everything but the value of nothing. Without good affordable and widely available education there will be no development, no drop in HIV/AIDS rates, no flourishing local commerce and industry, no drop in the unemployment rate and Zambia will risk becoming a stagnating and underdeveloped economic back-water.

We hope the political will is there to address this.

Doing More with Less

INTERNATIONAL AIDS DAY - Getting To Zero

Zero new infections, zero discrimination and zero Aids related deaths
(this year's theme)

There is good news from a recent UNAIDS report released for World AIDS Day (1 Dec). www.unaids.org/en/resources/unaidspublication/2011/  New HIV infections and AIDS-related deaths continue to fall, and the number of people on treatment in the less developed world is almost 50 percent of those eligible. This has happened in spite of a decrease in finances.

Especially encouraging for us in Zambia is that access to HIV treatment has improved greatly in Sub-Saharan Africa (SSA), the region which has long been worst hit by the AIDS epidemic, making up some 68 percent or 22.9 million of all HIV-infected people.

Access to antiretroviral drugs (ARVs) has increased in SSA by 1/5 between 2009 and 2010 though 1.2m people still died of AIDS-related causes last year. Zambia has reported coverage levels of between 70 and 80 percent; nearing universal access (considered 80%).

The overall world statistics are encouraging too; while 2.7 million people contracted HIV in 2010. This represents a fall of over 1/5 since 1997.

6.6 million people are now accessing ARVs , an increase of 1.35 million in less than two years. With improved access to treatment, new HIV infections are also declining sharply.

It seems that ARVs play a role in reducing transmission of the virus to partners. Infection rates are 1/3 to ½ fewer than would have been the case without ARVs. This amounts to 2.5m people alive today who would not have otherwise been.

Changes in behaviour such as abstinence, condom-use and male circumcision are also contributing. Prevention of mother-to-child transmission is another success, where 400 000 new infections have been prevented.
To continue to do more with less, the UNAIDS Report suggests a 4- Goal Investment Framework to use funding more efficiently and effectively.

1.Maximise benefits of HIV Response

2.Use national epidemiology to ensure best allocation of resources

3.Implement programmes based on local context

4. Increase efficiency in prevention treatment care and support

This new approach in funding could prevent some 12.2 million new infections - including 1.9 million children, and 7.4 million AIDS-related deaths between now and 2020 says the report.

For universal access to HIV prevention, treatment, care and support by 2015, an estimated US$22-$24 billion annually is required.

In the past two years donor funding has been cut by 10 percent from $7.6 billion in 2009 to $6.9 billion in 2010.

Without stable funding, opportunities to prevent new infections will be missed and there is a risk that the progress gained in the fight against HIV could be lost.

Our Aids Relief Programme at the Mission Hospital here in Mwandi continues with its static clinic based here at the hospital and the 6 mobile outreach clinics. The outreach is now undertaken weekly. There are 1478 people on ART, 164 of whom are children.

We are grateful to many people for being able to look after our clients in many different ways. Starting at the top we have PEPFAR and AIDS Relief with the funding and other structural and logistical support. On the ground here we have a number of Church Partners who help such as IPC with reagents, Aiken and Goldsboro and other individuals for their contribution to the Formula Programme. There are over 250 children alive today who benefited from this programme that uses WHO guide-lines. The Church of Scotland Guild ’s Food Support programme that brings nutritional support to the Hospital and Home-based Care programmes. There are numerous churches and visitors who by buying bags and craft items made by the Mothers’ Support Group give this group a small but steady income throughout the year.

This year in Mwandi the Community will meet as usual on AIDS Day Eve for a candle-lit service in memory of those who are no longer with us and who have been lost to HIV/AIDS. At the service we will have a large number or Orphans and Vulnerable Children, a visible legacy and testimony to the destruction caused to ordinary families by this appalling pandemic. It is a sad and moving occasion but also one of joy and hope in the presence of these children.
The next day, AIDS Day, there will be a march through the village, an all-age gathering for some speeches, songs and drama; a Fun-Run and Football Match are the sporting events planned.

Doughville

Following the G8 Summit in Deauville in France, we hear the promise of more transparency by these Governments with their aid. This will involve the quality and outcomes of their aid. There will apparently now be a two-pronged approach: the quantitative reporting of disbursements and also a qualitative approach based on effectiveness, the measurement of results and best practices.

While this is encouraging, Oxfam have accused the G8 of manipulating figures to cover up shortfalls and ignoring inflation. To improve matters it is suggested Governments sign and implement the International Aid Transparency Initiative which provides a common standard for defining and disclosing aid information. This would make it easier to compare aid budgets and projects.

Transparency is vital to ensure that aid reaches where it is supposed to go. It is useful for taxpayers, NGOs and donors to be more efficient and could help expose corruption. It would help ordinary people to track the money – from the donor down to the jotters delivered to the school, or the vaccines to the rural health post. It will also make it difficult for donors not to give what they have promised in the fight against poverty and injustice. In Zambia it would be good to know how much aid the government is receiving, and how it is disbursed. Aid information needs to be comprehensive, comparable, current and accessible.

This week we learned the Zambian government has just received funding of about US $300 million from the Global Fund after the government returned part of the money and promised to pay back the rest of over K9.1 billion that was mismanaged by recipients. These funds were meant for the fight against HIV/AIDS, Malaria and TB.

The re-imbursement of misappropriated funds has been justified by saying Zambia would not have received this new funding had the refund not been not done.But the refund of the misappropriated K9.1 billion to the Global Fund has not come from those who had originally misappropriated the money but from front-line cuts to the Health Budget.

Recent statistics showed that the formal employment sector in Zambia employs only about 10% of the available workforce. With so few formal jobs, small informal businesses such as tailoring, hairdressing or a small grocery stand or tuck-shop known locally as a ‘Kantemba' are run by many families here. Other outlets in Mwandi provide firewood, furniture, vegetables and fishing-nets. Profits from this kind of trade are often small and offer little opportunity to expand the business.

Zambian banks take little interest, though they earn great interest, in lending. The present annual Interest Rate is around 50%. Our nearest bank is in Sesheke over 70km away. The required minimum opening balances range between $150 and $300 depending on the type of account. This is far beyond the reach of most Zambians. Even monthy servicing fees are more than $10. A retired Headmaster we know is charged a K20 000 ‘service fee’ each time he withdraws his monthly pension of K90 000!

With most of the people living on less than a dollar a day, these minimum balances are designed to prevent most people from having access to basic banking services.

More people are instead turning to microfinance institutions (MFIs) which are increasingly becoming more accessible. Two groups, have with American church help, started this month at Mwandi. Unfortunately most people here have still have little choice but to turn to loan sharks.

There are only 25 MFIs registered in Zambia, and the total number of borrowers it is reckoned at less than 100,000. How to make banking services and reasonable credit facilities available and affordable to a majority of Zambians is a problem, but necessary to solve if the economy is to continue to grow and the country develop.

After all this talk of Mammon perhaps a little related linguistic levity is in order, especially for Scottish readers in particular - threats of banker super-injunctions forby. We sometimes get our messages in Katima Mulilo in Namibia which is just across the Zambezi from Sesheke. The two main Banks there rejoice in the names, believe it or not, of ‘FNB’ (Apologies to Matt McGinn!) This officially stands for First National Bank. I leave any locally suggested alternatives to your imagination. The other is called Nedbank! We wonder if this name is a reflection of the corporate leadership or of the clientele

And finally the Chinyanja for ‘No’ – the main language in Eastern Province, is 'Awe' pronounced: Away.

As in away ye go!

Missing Money, Missing Drugs and Missing Jobs

One of the consequences of the suspension of funding to Zambia by the Global Fund to fight AIDS, Tuberculosis and Malaria, has been an increasing number of stock outages and drug rationing that has affected all hospitals nation-wide, Mwandi Mission included.

Stock outages at clinics and hospitals have been so far fairly short term, but Central Medical Stores have sometimes run out of stocks for a considerable period as they wait for emergency shipments to arrive. In cases of low stock levels, drugs are rationed.

Regular readers will remember in an earlier blog the covering of the allegations of corruption at the Zambian Ministry of Health (MoH) uncovered by an investigation by the auditor general. The audit found that the ministry could not account for more than US$7.2 million. The repercussions from this are still being felt.

Another audit undertaken by the Global Fund* reported on poor financial management at the MoH, Ministry of Finance, the Christian Health Association of Zambia (CHAZ) and the Zambian National AIDS Network. These bodies used to receive Global Fund monies directly for programme implementation and then pass funds on to other organisations called sub-recipients. The audit found that $10.7 million of Global Fund money was not passed on and, to date, none of it has been repaid. The alleged financial mismanagement includes the purchase of vehicles for personal use, inflated salaries - sometimes more than double the going–rate locally, and funds disbursed to sub-recipients who could not provide auditors with financial records.

The Global Fund only funds CHAZ directly now; the MoH no longer receives funds, its responsibility in this area has gone to the United Nations Development Programme (UNDP) in Zambia. Teething troubles with these new procedures have brought delays for us on the ground in receiving funding for our AIDS Relief Programme. We have also suffered two major stock-outs of antiretrovirals (ARVs) recently. Fortunately we had a Hospital vehicle in Lusaka at the time that waited for one of the drugs to arrive in the country. We are relying on UNICEF and USAID who are scrambled to bring in more expensive emergency supplies until the new bodies get their procurement procedures properly functioning. TB drugs have also been in short supply. A week’s supply of the children’s ARVs was borrowed from the District Hospital.

The knock-on effects from this was that we could only give a week’s supply which meant the children and parents having another walk in a week’s time to the Clinic to receive the rest of the month’s supply. This meant further unbudgeted transport costs for the rural poor with an increased risk of defaulting and subsequent resistance.

Those responsible for the misuse of funds are still not being held accountable. It will be up to local courts to prosecute those suspected of fraud or the misappropriation of funds. Civil Society and some NGOs are pressing for this. Patients and clients in this area rely on these funds to provide their medication; if there are no drugs available or they are in short supply they need to know why. They have a human right to universal and equitable access.

Linked to this we have four workers facing immediate redundancy. The Government has recently been recruiting mission workers and has put on their payroll some who were formerly paid by CHAZ through a grant from Government which came originally from outside donors. The Government is keeping that grant to pay workers directly. CHAZ workers who are under 45 years of age and in possession of a Grade 12 School leaving Certificate were eligible to apply. The grant to the Hospital to pay the CHAZ workers is being cut in proportion to the number of workers put on Government payroll and linked to the ‘on paper’ establishment. So we now have four over-aged or under-qualified workers with many years of good experience and loyal service who are about to be thrown on the scrap heap as surplus to requirement. The change-over was supposed to be done over time and using where possible natural wastage. The Hospital cannot at the moment generate enough independent income to pay them or pay their retrenchment package.

Like our clients and patients living with HIV and Aids, these four people are another set of victims of the world’s greed and injustice, their dignity in work destroyed. Wealth that has been given generously is not shared fairly but kept in the hands of a few and misused to promote inequality and injustice.

*The full report can be found by googling 'Global Funding Country Audit Zambia'

Trip out for the Mobile ART Clinic and Community Meeting

A few weeks ago the Aids Relief staff came back from a settlement 90km away from here saying that they had had a very difficult clinic. A mentally-deranged women had set fire to the thatched roof of the New Apostolic Church, so they only had had one room for the clinic. The choir was also rehearsing where we usually met and patients did not want to collect their medicine from the back of the vehicle in case they were seen. One member of the Team felt that we should move the neighbouring clinic further south - more convenient for us, but further to travel for most of the patients. We discussed the problem at our monthly meeting but the staff was divided. As chairperson I came in and said that this was not our decision but the decision of the affected community. Our Adherence Counselor took the message back that they should hold a meeting and then we would come to meet the Community and hear of their decision.

Yesterday we set off late at 0930h in the pouring rain, for the two hour trip. The road is usually sandy but today it was just muddy porridge. The trucks picking up maize that had been sold to the Government had churned it up making it very treacherous. We arrived at 1130h with the sun beginning to peep through the overcast clouds. Today, we were given two rooms at the New Apostolic Church, a typical pole and dagga building. Four clients were already waiting for us, three as appointed and one who should have been the week before.

As we began the clinic more clients arrived. One lady came for her CD4 results. She was found to be positive when she delivered her baby recently. I began to fill out the forms with her for enrolling her. She gave her treatment supporter as her husband. When we reached the part that asked who she had disclosed her status to she answered no-one. We stopped and went back to the Treatment Supporter. No, her husband did not know and he would divorce her if she told him. Could she not persuade him to come for testing? No, he is difficult, was the reply.

I called the Adherence Counselor and together the three of us decided that when we come for the next clinic the VCT team would do Door-to-Door VCT in her village and hope to test all the family, including the husband, and also re-test the client so that they hear the results together as a couple.

It was now time for the meeting, the Community were sitting outside; people of all ages and the Headman seated in the middle. We greeted one another and went through the formalities. The Headman then explained that as a community they had held a meeting earlier and this is what they had decided.

The clinic would no longer continue in the New Apostolic Church but that they would build a new clinic. They had already started. Those who could, had donated a bucket of maize which was sold to the Government Agents who are purchasing relief maize. With this they had bought eight roofing sheets. The Headman explained that they had cleared the land and begun cutting poles. They felt that four rooms would be good but that that would take 20 roofing sheets in total. He explained that a few more people had donated but it is a difficult time of year as last year’s maize is finishing and they are all trying to purchase seeds and plant again now that the rains are here.

I thanked them for their efforts but explained that the Aids Relief program was unable to help. I said that I could not promise but I might find some help towards the roof but meanwhile they should keep on trying to raise the money. I also said that I was sorry that not only the church roof had been burnt but also the community school’s roof by the same woman.

From there we moved on to discuss stigma in the community. Why were people afraid to be seen receiving medicines? (A drunk man answered that he did not have a problem.) I said that this was a issue that they as a community should try and address and instead of hiding from each other they should be caring for each other and their needs. I then went on to suggest that they should be thinking of some form of Income Generating Program to help support the Community Health Workers and the clinic. They should also be considering beginning home-based Care.

We ended the meeting and waded through the mud across the road to look at the site that had been cleared for the clinic. 

We have a lot to thank God for!

Wishing you all the best for Christmas and a Happy New Year

Glossary
ART: Anti-retroviral therapy, drugs used to suppress HIV virus
VCT: Voluntary Counselling and Testing (for HIV)
CD4 Count: the level of unaffected white cells in the blood.

A day in the life ...

On Tuesday morning I received a phone call from the Home Based Care (HBC) Coordinator. One of their clients who was bedridden was refusing to go by taxi to keep her Pre Art appointment at the Hospital. Could I help? I agreed and drove through the village, along the very narrow sandy road between pole and dagga houses with their thatch roofs. Young children came running out to wave and chase the car. I stopped and picked up Lilly the HBC carer for the clients in that area. We drove on together a very short distance.

I knew the client, Namatama, as we had had her in the hospital and recently discharged her. Namatama contracted TB four months ago and was also at that time tested for HIV. Because of the TB she could not start Anti Retroviral Therapy (ARVs). She had also recently been in the hospital suffering from PCP, a lung-disease linked to Aids. The usual dusty and ill-clad children greeted us excitedly. The family rushed around to bring chairs to her tiny mud and thatch house. I went in to a dim room with a metal bed in the middle with a thin mattress and chitenge ‘sheets’ (cotton wraps) barely covering the bed. In the middle was Namatama skeletally lying with her face to the wall. We sat down and gave the traditional Lozi greetings. I got up then and insisted on greeting Namatama. This broke the ice with Namatama. I think most people discuss her rather than include her.

She proudly said that the bedsores that she got in the hospital had healed thanks to Lilly. Then she told me that she was hungry but could not eat the food that the family prepared for her as they kept frying everything and the Nshima (thick maize porridge) the staple was too heavy. The bag of soya that she was given by the project remained unused, as it was too strong for her. We then tried to discuss what she could eat and the answer was nothing. Anything the family offered her just gave her diarrhoea. She said that the ORS which Lilly had given her was making her stronger. I then tried another tack if she could choose what would she most like to eat? I smiled at the answer, a boiled potato. We are probably one of the few homes in Mwandi that has potatoes!

I then broached the subject of her appointment. She said that to ride in the car would be too painful for her lungs. We continued our discussion for a short time longer but Namatama was adamant that she would die if she went back to the clinic. I then frankly told her that if she did not go she would die anyway!
I stood up and said that we would pray but before I prayed would she agree to come back with me to the Hospital? She agreed and then we prayed.

Namatama sat in the front to the Hospital with her younger sister and Lilly in the back. Her real fear was that we would insist that she was admitted to hospital yet again. When we arrived I fast-tracked her to see the clinician. She weighed only 33kg. She had lost 10kgs in a month.

I left Namatama with the Clinician and went home and found some potatoes, carrots and a litre of milk.

As I was going back into the clinic I was stopped by a nurse to say that there was a mother and baby waiting for assessment. Mum had stopped feeding the baby at six months because she was HIV +. The baby was now 8 months looked very small and anaemic. The nurse said there is a slight problem in that she is from Namibia. She had come across the Zambezi in a mukolo (wooden canoe). I still enrolled the baby in the formula program as the border is only a colonial border. The people are all of the same tribe and often have relatives on both sides.

Namatama had had bloods done the CD4 was now 22. The clinician felt that she might not manage to take the ARVs as Namatama had said that the family were going at the moment to their fields to clear and plough all day and they did not believe that she was HIV+. The clinician and myself went and spoke to the Doctor. I put forward my case that Lily could step in and give the medicine in Namatama’s home until Namatama could manage to take it herself. It was agreed that Namatama would start on ARVs. Lily went with Namatama’s sister to the Pharmacy for Adherence Counselling and to learn about the medicine. Lilly herself is HIV+ so she understands. Triumphantly after two and a half hours we brought a tired but serene Namatama home.

A lesson was learnt. The food on the project did not suit everybody. We will have to buy for our clients what is best for them.

I came home in time for my Lozi lesson. The Lozi teacher, a retired English teacher, was waiting patiently for me. We have been translating together a pamphlet in English about TB into Lozi. The teacher then has lunch with us as he too is in need of a meal.

Keith came home from school worried. Kandiana the old folks home has run out of food. The government have not sent any money since August. He had been eking it out since then but there was no money left. Can the Guild project help? Fortunately, over half of the residents are HIV+ so beans , kapenta(dried whitebait) and a few other things are purchased. The Mission Farm promises to supply maize ,eggs and meat. They have also run out of firewood. We had a storm the night before that caused a large branch to fall just missing our car, so at the end of the day there is the sound of axes chopping up the branch and the old people who are able dragging the wood away.

The day is another testimony to the grace and providence of God in our lives here.

(We changed people's names for confidentiality)

On home ground again

We are at present limping our way to Livingstone on a very worn front tyre due to continued suspension problems and after having the problem supposedly rectified in Lusaka. We are to pick up Jennie Chinembiri and George Lind (of the Church of Scotland's World Mission Council) from the airport while doing various items of business for school, manse and hospital.

The Reverend Silishebo has demitted office after 8 years at Mwandi and has been called to the Chaplaincy at the University of Zambia in Lusaka; the Reverend Derek Lubasi who is presently at Coillard Memorial in Livingstone will be inducted shortly as our new minister. There is a flurry of activity cleaning, painting and renovating the manse to welcome the new ‘family’ (Lubasi means family in Silozi.)

We have just spent the past week-end doing another flitting! We have moved into Hippo House – bit of a misnomer as far as size is concerned but we are fortunate to enjoy running water and electricity (most of the time) utilities denied to a large majority of the Zambian population.

Some progress has been made with the house that the Church of Scotland funded with a grant, and that Nick designed and is building. The wooden flooring is being laid at the moment. We hope we can move in before Christmas.

We are beginning to pick up the threads of where we left off. On the first Sunday evening we got back was a very moving service for the sending out of the 10 young people back to their congregations. They had been attending a 4 month Mission Course at the Church run by Percy, the Youth Pastor. They had slept in tents, cooked for themselves and freely contributed their talents and labour to various ministries to be found at the Mission. They had also has their faith challenged and deepened, intellectually and academically too they had a substantial amount of reading and writing to tackle, not just of a theological nature either but also other work needing life skills.

We have had a good and useful couple of days with Jennie and George who were able to get a taste of what we do at the Hospital and School as well as the wider Church work we undertake here. We saw them off on Saturday to Kitwe and Lusaka.

We are now back to ‘auld claes and porridge’. Ida is back to work at the AIDS Relief Programme, she has done the first scrubbing for a Caesar and has been returned her keys and asked to tackle the Central Stores which was neglected in her absence. She is a Also working with the Consistory, helping to establish a home-based care programme.

As for me I have been allocated Grade 8C for Maths and Science and 10A for History. I am at present drafting a proposal to submit to a Church Aid for teacher housing at the High School. We are still putting the finishing touches to the second classroom block and student latrines which were not finished despite efforts on my part to ensure that things should continue in my absence.

Another exciting development hoving into view is the possibility of a Community School at Sikuzu. Sikuzu is a rural community about 8km downstream from Mwandi. The children are prevented from attending school at Mwandi until they can walk the return journey each day. They are usually 8 or 9 years before this happens. So a Grade 1-4 School will be a great boon for them. At present there is a UCZ Pre-school run from the Church.

Sturm und Drang in Vienna: Our diary

Saturday 17 July: The Multi-Faith Pre-Conference of the International Aids Conference met at the Technical University. The opening religious ceremony was excellent, with all the various faiths found in Vienna taking part. It was also good to see that WHO are giving due recognition to the work of faith-based institutions on the ground but sad to hear that PEPFAR have 'straightlined' their funding. Ida found it a good forum to raise two major concerns she had on the unsuitability of some of the paediatric ARVs and the lack of variety in comparison with adults. The pharmaceutical companies need to be lobbied on this issue. Returning to PEPFAR, if budgets continue to be reduced, then universal access will fall by the wayside and faith-based institutions will end up having to play God which is not their role. Those two points were picked up and used during the conference by more authorative speakers.

Sunday 18 July: The Opening of the Conference with the 18th Life Ball which was being held out of doors at the Rathaus was washed out by a tropical thunderstorm called Petra just as Whoopi Goldberg dressed as Mother Earth started to sing. The great and the good including Bill Clinton, Mette-Marit, the Crown Princess of Norway and various other prominent German-speaking politicians and celebrities rushed for cover including 50 black Promenade Dancers dressed in white and 50 white dancers dressed in black, while those in fancy dress including avatars, fauns, elves and pixies plunged into the fountains. Other prominent personalities present were Boris Becker, Patti Labelle, Prussian and Austrian Princesses plus the Mayors of Berlin and Vienna. Unsurprisingly, there were no Scottish peasants invited.

Monday 19 July: The first Plenary Session of the Conference and Bill Clinton's keynote speech was a highlight. Regarding funding Faith-based Institutions should lobby Congress to make the right choice by supporting, continuing and increasing funds for care, treatment, infrastructure and systems. Greater care and stewardship was also a pre-requisite for a dollar wasted puts a life at risk. Jobs need to be done faster, better and cheaper, in other words doing more with less. African governments need to keep their part of the bargain and devote at least 15% of their national budgets to Health Care. As regards prevention, scaling up should be done with what works. Large sums of money of money can be raised through small amounts given by many people. Education and advocacy are priorities.

Ida presented her poster entitled The United Church of Zambia Mwandi Mission Hospital Voluntary Counselling and Testing Strategy for Hard-to-Reach Populations. This dealt with a mobile outreach program that visited social events and rural and fishing settlements to increase the number of people who know their HIVstatus, so that they can access the HIV Programme before they are ready to start anti-retroviral treatment and become sick.

Tuesday 20 July: The main event was a peaceful but noisy demonstration through the streets of Central Vienna by 15 000 people on Tuesday evening to show solidarity with the campaign for human rights throughout the world and especially for those living with HIV and Aids. It also called on Governments around the world to increase funding for fighting the disease. An interesting fact: the Church of Scotland has given much more money to the worldwide fight against HIV and Aids than the Austrian Government, who to its shame gave a paltry single contribution of E1m to the Global Fund away back in 2002 for condoms for Africa..It was pointed out that the city of Vienna would be benefiting to the tune of E45m going into the local economy from hosting this conference alone. The Demo closed with a live concert given by Annie Lennox, the former Eurythmics singer, who is now the United Nations AIDS Goodwill Ambassador.

Wednesday 21 July: Marjorie Clark's Presentation of the Church of Scotland's HIV/AIDS Project at the Global Village. This was also another good opportunity for networking. Marjorie explained that the Church of Scotland”s Programme started in 2002 and its position was reiterated in 2006. It is to bring life and hope by breaking the silence on HIV and Aids and standing with partner Churches to offer practical support and to speak up for the voiceless, involving all Church members. This year the project becomes an integrated programme of the World Mission Council.

One of the most successful fundraising ventures had been Souper Sunday. Congregations had a simple soup and bread lunch after a Sunday Service in January. Last year over GBP100 000 was raised in this way from over 300 individual Churches. These congregations' generosity was a good example of many smaller sums of money adding up and together making a considerable amount. Mony a mickle maks a muckle.

Thursday 22 July: A good day for hearing about the new WHO PMTCT (Prevention of Mother-toChild Transmission) and Feeding Guidelines. The mothers will in the future be covered by ARVs until they stop breastfeeding. This will mean that more babies should be able to be breast-fed. This is a step in the right direction but in an ideal world all pregnant HIV+ mothers would be able to access long-term triple therapy anti-retrovirals.

The integration of palliative and home-based care at a workshop was another useful meeting and contacts made for future-training. This is an area that is lacking at present in Mwandi but steps are afoot to work at this through the Woman's Christian Fellowship in our 13 out-of-station preaching points.

Another interesting talk was given by a Dutch doctor based in Mozambique who has formed his ARV patients that default into cell-groups that help support each other, provide a form of mutual accountability and pick up ARVs for each other. This is a simple and effective way of cutting down waiting time in queues and transport costs for these patients. This can only happen with stable patients but is another good idea that can be adapted for use by the Mwandi Programme.

Friday 23 July: The closing day. The Global Village is being packed up but nonetheless excellent presentations on the maltreatment of prisoners living with HIV and Aids in Eastern Europe. It has been good to see how HIV and Aids affects other areas of the world and not just Africa.

We have also managed to visit Schoenbrunn Palace and the Spanish Riding School. Keith Catriona and Mubita also toured the Zoo, went to a Gustav Klimt Exhibition and did a cycle-tour of the Wachau are where the imprisoned Richard the Lionheart was found by Blondel, the inconclusive Battle of Duerenstein between Napoleon and the Austro-Russian Coalition in 1809 and the Anti-Freeze in the White Wine Scandal of 80s.

On Saturday 24 July we set off by rail for Geneva via Zurich.

Church of Scotland General Assembly

After seven days of meeting, the General Assembly closed on Wednesday last week. It was a good time listening to the debates and meeting up with friends from all over the country. As the Church continues to share and spread the Gospel throughout the world, it is amazing the diverse interests, concerns and needs that this brings to light as people speak and we hear often prophetically about passions shared or pain that we attempt to understand and address.

All this feedback and information is living proof of Paul's metaphor in Romans 12 that in Christ we form one body belonging to each other all with different gifts depending on the grace given us with the further development of that in 1 Cor 12 that we are made up of many parts and as a body there should be no division but we need to show equal concern for each other in each of our own joy, pain and sorrow.

Business started appropriately with the Scottish Bible Society and we heard how the Word of God shapes lives here and overseas, contributing to the work of the Church: we have a vested interest here as Ida's mother worked for the Bible Society for many years.

Friday was another interesting day with the 'Third Article Declaratory' being debated concerning parish-based ministry bringing the ordinances of religion to people nationwide. It was interesting and sobering in the World Mission Council Report to hear from minority-status Christians who suffer for the faith. There were deliverences to raise awareness of this amongst elected politicians from Holyrood, Westminister and Brussels. Another echo of 'If one part suffers........' This was also mirrored at home by the work of Crossreach which includes counselling, addiction help, assisting prisoner families and the care provided for the young the old and the infirm of all ages, - the frail and the rejected.

Morning Service at St Giles' Cathedral was followed later in the day by a special service marking the 450th Anniversary of the Scottish Reformation. A wonderful time of reflection on the influence of the reformation on education and on wider Scottish society. It was a medley of Psalms, Prayer and other Scripture cleverly interwoven with monologues, dramatisations and presentations on the theme.

The overall message similar to that delivered from George MacLeod celebrating the 400th and resonating from 16th century - A Reformed Church is forever to be reformed. In other words to make God alive and relevant for people today. Interesting too that there is no longer the same contraversy over the morality over the possession of nuclear weapons. The Church's position on them and Trident is thankfully unequivocally clear.

Monday was good with a report from the Children's Assembly, not just the future Church but part of the Church here and now. A reform of the Presbyteries is envisaged to make them more responsive and better able to deal with the changing needs of the Church. The Guild and their support of HIV and Aids at home and beyond. Ida spoke here wanting to raise awareness of the impact of HIV and AIDS locally at Mwandi and asking the Church to advocate on their behalf to continue to make a difference to the lives of many living people worldwide with this disease.

We heard the report from the Armed Forces Chaplains who look after the spiritual needs of members of the armed forces and their families wherever they are serving. Not an easy job. There is also need of a ministry for forces personnel once they retire to help them adjust back to civilian life again. Safeguarding children and other vulnerable people and the safe inclusion of sex offenders in Congregations came in the report 'For such is the Kingdom of Heaven.'

The Assembly closed on Wednesday with amongst others the Iona Community Board Report, again another area of personal interest to us, Ida's father helped to roof the Abbey just after the War. It was good to read of the good work being done countering sectarianism and working with young offenders.

Finally, another highlight for us was the address by Mona Siddiqui.

Looking back on all this, the Church at this Assembly has identified its task as not only to get out there and talk about Jesus but also to be someone to speak for the poor, those who are marginalised socially, politically, economically, educationally and medically and in doing this it needs to engage in effective advocacy in partnership with civil society and other faith communities.