Grace Matnanga is a happy woman. She is about as poor as you can be, earning the equivalent of R75 a month selling shoes from a tiny market stall. But her shy smile erupts into real laughter now.
In the past year something fundamental has changed. She has been spared the prospect of a premature and painful death. Matnanga is HIV-positive, as are one in three of those around her in the streets of Malawi’s capital city. But unlike them, and thanks to an act of human kindness, she has been given the chance to survive.
A year ago Matnanga (31) had the courage, in a society where Aids still carries a stigma, to tell The Guardian newspaper about her life and the virus that she knew could end it within the next few years. It had already killed her husband and her baby daughter.
Her story became the centrepiece of Saving Grace — an investigation of the obstacles to drug treatment through a chain of interviews with the influential, rich and powerful individuals who each had a part to play in deciding the fate of African women like her.
Now Matnanga is on anti-retroviral drugs. She takes one pink-and-white pill when the sun rises and a second when the sun sets. It’s no more complicated than remembering to get dressed in the morning. Yet she is one of only about 50 000 Africans on the drugs that suppress the levels of virus in the blood and keep people alive, while up to 28-million in sub-Saharan Africa have HIV.
For more than 10 years, the inadequacies of the hospitals, the shortages of nurses and doctors, who are poached in large numbers from Malawi by private agencies in the United Kingdom, the alleged complexity of diagnosis and treatment and above all the cost of the medicines have made drug treatment to stop the soaring death toll in Africa a non-starter.
Governments, aid agencies and doctors were paralysed by the problems, frozen in the headlights as the Aids juggernaut bore down on them. Now, thanks largely to grassroots campaigners, there is a real will to roll out the drugs. The World Health Organisation wants to see three million people on them by next year. Malawi officially launched its treatment plan last week.
In Matnanga’s case, a Dutch doctor, working as a locum in Lilongwe intervened. Dr Hetty van Dijk read Matnanga’s story and sent a driver to find her in the market.
After a blood test and medical examination, the doctor decided to fund an ongoing programme of anti-retroviral drug treatment. Each month Matnanga takes the bus to the Lilongwe clinic, where she collects the money for 60 more tablets and hands in the previous month’s receipt.
Now back in The Netherlands, Van Dijk is setting up a Saving Grace Foundation to match willing donors with individuals who need treatment. But already five more Malawians, who could not possibly have paid 2 500 kwacha (about R150) a month for drugs are being sponsored.
”I am very happy,” says Matnanga, ”and I feel well. Those people in the market say how come people can come all the way from very far just for you? What is special about you? I said I’m just lucky. It is just by grace of God.”
She prays for long life for the Dutch doctor, she says, laughing, ”because when she dies she will stop paying for the drugs”.
The saving of Matnanga is a small miracle in a dire situation. A bigger miracle may yet take place. For the past year Malawi’s government has been working hard on a programme to get drugs to as many of its people as possible, including those who have no hope of paying. There are 300 000 people in Malawi in need of the drugs, out of nearly a million infected with HIV.
The United Nations’s Global Fund for HIV/Aids, Tuberculosis (TB) and Malaria eventually approved enough money for 50 000.
From July 1 the Ministry of Health hopes most of the country’s 78 hospitals — 50 of them in the private sector — will start treatment with anti-retrovirals, each putting up to 25 people a month on the drugs. Like Matnanga, they will be given Triomune, which is a combination of three drugs in one pill, made by the generic drug company Cipla in India, which has copied the inventions and drastically undercut the prices charged by the giant multinational companies.
For now, companies like GlaxoSmithKline, which were trying to block what they see as the piracy of Cipla and other generic companies, seem to have lost out in Malawi.
”It is a bold plan,” says Tony Harries, a British-born professor of medicine working on Malawi’s Aids programme. ”We’re probably losing 85 000 people a year because of Aids and it may be more than that. It is a moral imperative to get a move on with a drug that can save lives.”
But there will not, at least at first, be enough drugs for all. Some, Harries among them, think it should be a case of first come, first served. Others say no, there has to be a rationale. If people are to be turned away, they must understand why.
Expectant mothers can already be given drugs to prevent them passing HIV to their babies during labour. So treat the mothers, or those babies will soon be orphaned and may not survive. Give the nurses and doctors the drugs, or they will not be able to treat others. Give them to those like Matnanga, who are brave enough to go public, to encourage others to be tested.
What is almost certain is that if there is a cost to the patient, it will be tiny, probably no more than 200 kwacha (about R12) a month. At the Lighthouse clinic in Lilongwe where they have to charge cost price — 2 500 kwacha (about R150) — about 40% drop out because they reach a point where they can no longer afford the drugs. In Chiradzulu in the south where Médécins sans Frontières offers drugs for free, the dropout rate is less than 10%.
There is a greater problem. Walk into any of Malawi’s hospitals, and it is shockingly obvious. Beds fill the balconies outside the wards of Lilongwe Central Hospital. In Kasungu District Hospital to the north, there are 179 beds and often 400 patients. On the day we visited, 101 children had been admitted for 13 paediatric beds. Two babies having blood transfusions lay on one adult bed, with a third on a drip.
Yet Kasungu has 29 nurses instead of the 50 it is supposed to employ. Lilongwe has 169 nurses when it should have 532.
”On the medical wards there are 50 to 60 patients to one nurse,” says Central hospital director Dr Damson Kathyola. ”Some shifts we are unable to cover so there may be one nurse to 100 patients. You can imagine how that is affecting the health-care workers. They are overworked. They are burnt out after some time. They can’t cope with it and they give up.”
They go to ”greener pastures” in the UK or work forNGOs within Malawi that pay foreign salaries.
About 70% of patients in the wards of Malawi’s hospitals are there because of HIV/Aids. Pneumonia, a skin cancer called Karposi’s sarcoma and shingles are among the HIV-related common killers. Death rates from malaria and in childbirth have gone up because of HIV. The drugs are the best chance of checking the nightmare human flood.
”If we have free drugs, it will reduce the number of admissions and the workload on the nurses,” says Kathyola, adding without pause the other half of the vicious cycle. ”The question now is how we get the capacity to deliver the drugs. We have got a depleted workforce.”
His answer is more pay. Nurses get 1 000 kwacha (about R60) to 9 000 kwacha (about R550) a month in his hospital before allowances, but can earn 40 000 kwacha (more than R2 400) in the private sector.
Ironically, better pay for health-care staff was one of the elements Malawi was advised by donors to cut out of its bid for money from the Global Fund.
Vice-President Justin Malawezi, the political driving force behind the Aids plan, would have liked faster progress in the last year. ”I’m afraid we have not got as far as we had hoped we would get,” he says. ”However, the commitment is still there very strongly at all levels. All the policy documents and guidelines are in place.”
But he complains of layer upon unnecessary layer of bureaucracy and form filling. ”It is delaying the whole process. Meanwhile, people are dying. The government is losing credibility because it hasn’t achieved this. The people working on the programmes are getting frustrated because they don’t see the fruits of all their hard labour. I think it is very important that the Global Fund managerial system has to be simplified. We have an emergency on our hands.
”We think there should be efforts to reduce elsewhere, such as on military expenditure. Stealth bombers cost $7-billion. The Global Fund only needs one of those. I don’t want to affect the fight against terrorism but it could be done in other ways.”
Nobody underestimates the scale of the task or the potential for things to go wrong and everybody wishes it could happen faster.
Matnanga has been saved, but it is too late for Dessa Chithadza, the second woman featured in The Guardian last year. Her bed in the family’s front room has gone. So have the formal lace cloths, exposing the rips in the chair arms, and there is a jumble of boxes and washing in what was a pristine if dark and crowded parlour, reflecting the turmoil of their lives.
Chithadza (29) knew she was HIV- positive and was prepared to talk about it. She had been for a test after her husband died of Aids. Martha Chithadza (33), her elder sister, did not want to know why she was so ill. Martha died first, on September 29 last year. Dessa Chithadza contracted TB and in spite of treatment, grew weaker and weaker. The Dutch doctor sought her out too, but little could be done. She died on December 13.
Rose Chithadza (53), their mother, has lost all last year’s jollity. She sits sombre and very upright, managing her troubles with dignity.
Her husband was a truck driver, away much of the time but bringing in money. He too died, on January 19 this year. There are 14 people living in the house, but with few prospects. Bothwel (23), the only son, had to give up his training as a mechanic for lack of money.
As Rose Chithadza says goodbye, her two-year-old granddaughter joins her on the front step. Her name is Grace. The hope in Malawi is that, by the time she grows up, this Grace will not need saving. — Â