IHT: A Malawi AIDS patient's exceedingly rare choice
Just 30 nationwide get costly 3-drug therapy.
By David Finkel Washington Post Service Paris, Thursday, November 2, 2000 This article first appeared in the International Herald Tribune
BLANTYRE, Malawi - The surprise in this diseased and dying place is not the man with AIDS, it is the sheets on his hospital bed. They are
clean. They are ironed. They are a pleasant design of pastels. And most
important, they are soft, giving immeasurable comfort to the
50-year-old man who is tucked in between them, listening in silence as
his doctor explains what it will take for him to become one of the
luckiest people in Malawi.
"So there are two issues you would have to be clear on," the doctor,
Jack Wirima, is saying. "The first one is the duration of the
treatment. It would have to be taken for a long time."
"For life?" asks the man, whose first name is Yasaya, whose voice is
faint, whose arms are well on their way to bones.
"Yes. For the rest of your life. That's the first. And the second is
the cost," Dr. Wirima goes on, explaining that the price for the
treatment works out to about $10,000 a year. The treatment involves
three drugs that, taken in combination, can prolong the life of an
AIDS patient significantly. In the United States, where the treatment
has become standard, the AIDS-related mortality rate fell 75 percent
in three years. But in Malawi, one of the poorest countries in the
world, and one of the sickest, the treatment is not standard at all.
The number of people who are HIV-positive in Malawi: more than 1
million. The number on triple-drug therapy, according to interviews
and records of drug inventories: 30.
"So," Dr. Wirima says. "Let me know."
"Thank you," Yasaya says quietly, and then he settles back,
wondering how he will be able to become number 31. It will take
several days for him to sort this through. He will have to decide what
to say to his wife, who prays for his health and sleeps in a chair
next to the hospital bed and tidies him up after he vomits, and has
yet to be told he tested positive for HIV, the virus that causes AIDS.
He will have to decide what to tell his employer, who he fears will
not want to pay for his care, and maybe will no longer want him as an
employee if his diagnosis is disclosed. He will have to decide how
much of his income he is willing to spend before staying alive
becomes, in his own mind, an act of selfishness.
The United Nations reports that HIV/AIDS caused 70,000 deaths in
Malawi last year. The disease has created 400,000 orphans in Malawi
since the first case was noted in 1984, reducing life expectancy from
47 years for a baby born in the mid-1980s to 36 for a baby born now,
and to this point, infecting 16 percent of the adult population.
"These unfortunate 1 million people," is what Wesley Sangala, a
senior Malawian health official, calls those in his country who are
infected. "What can we do?" he asks. "Really, what can we do?"
But even in the poorest, most devastated places, possibilities exist,
and in Malawi they can be found in a 64-bed hospital in Blantyre that
is surrounded by a tall iron fence and has a sign above the front door
that reads, "Right of Admission Reserved." This is Mwaiwathu Private
Hospital. And as the name, the sign, the fence and the guards at the
entry gate make clear, it is not for everyone.
Rather, as Dr. Wirima puts it, "If you can pay, you can come here."
Those who do include government officials and the business executives
whose medical insurance allows them access to a kind of care that most
Malawians simply cannot imagine.
Yasaya is one of those businessmen. Unlike most Malawians, who live in
villages, in huts that have neither plumbing nor electricity, he lives
in a house with several bedrooms and bathrooms and, dominating the
living room, a large television set connected to a satellite dish. At
night, he and his wife like to watch movies as they sit beneath family
photos and a wall-hanging that says, "Have Faith in God."
During the day, when he is not at work, he likes to rest outside in a
wicker chair under a large shade tree while his wife sits nearby doing
embroidery. It is a pleasant, upper-middle-class existence - or was
until Yasaya started to get sick.
Because their town is near Lake Malawi there are plenty of mosquitoes
around, and at first he suspected malaria. But it turned out to be
tuberculosis. Followed by malaria. Followed by illness after illness -
and weight loss, weakness, lethargy, a constant cough and a continuous
fever, which is why he was not surprised when an AIDS test came back
positive.
But even a year of sickness did not prepare him for how ill he was to
become. Late one night when he could not stop shaking, he went to the
emergency room at the government-run hospital. Like all public
hospitals in Malawi, it is severely overcrowded. Patients not only
fill every bed, they sleep on the floor. Nurses are scarce. Only the
most basic drugs are in stock. On that night no doctor was available,
so Yasaya, still shaking, went home.
And the following morning came to Mwaiwathu Private Hospital. Where
there are flowers in the foyer. Where the hallways always smell of
pine spray. Where, in a country in which the annual per-capita income
is less than $200, the charge for a bed is $50 a day
Where in one of those beds, Yasaya is explaining how he might have
become infected, saying maybe it was the time he had to carry his
dying brother, who was bleeding and too weak to walk.
"Or it could be the condom that broke. Or it could be the hospital.
Maybe they reuse syringes."
He looks at himself. He is on an IV. He is catheterized. He is, for
the moment, alone. His wife is out in the hallway. "It was sex,
basically," he says after a while. "But I don't know who."
What he also does not know: very much about anti-retroviral drugs,
which, though not a cure for AIDS, have had a dramatic effect on
mortality and morbidity rates in developed countries.
He does not know about the ongoing debate over worldwide access to
these drugs in which certain aid organizations are saying that
anything less than full access in even the poorest countries is
unconscionable, and drug companies are saying there has to be a
balance between charity and business, and any number of studies are
saying that even if the drugs were available, there are plenty of
other problems that would prohibit their administration.
He doesn't know anything about AZT, the first of these drugs, which
has been in use for 13 years. He doesn't know about 3TC, another
commonly prescribed anti-retroviral often used in tandem with AZT, or
about the subsequent discovery that a third type of drug used in
combination with the other two can restore an infected person's
immune system to near-normal levels.
It is this third drug, known broadly as a protease inhibitor, that has
offered the most hope for HIV/AIDS patients. But Yasaya knows nothing
of this, either, or that Mwaiwathu Private Hospital keeps a small
supply of a protease inhibitor called Crixivan locked in the pharmacy.
Or that it is the only place in all of Malawi that stocks Crixivan. Or
that a one-month supply costs about $500
What he does know: $500 is what he earns a month, after taxes; there
is a house to pay for and food to buy, and his children's school
tuition is coming due.
Of course, he wants the drugs, but if his company does not pay for the
treatment, "I would have to abandon it. It would be too costly."
Meaning? "I would die. Sooner than later. But sometimes dying is not
the end," he says. "I would just relieve myself of certain
obligations. If I live, the expectations of my family are very high."
Such are the unsentimental calculations of one man in a hospital bed -
and on a much wider scale of Malawi itself.
The government has acknowledged the scope of AIDS, producing an
official "strategic framework" for dealing with the disease over the
next several years. But the plan focuses on prevention. It pays hardly
any attention to those already infected. What about them?
"Well, they'll be dying at various rates," says Wesley Sangala, the
health official who oversaw the development of the plan.
How much of a priority is their treatment?
"In reality, we cannot entertain it," he says, sounding resigned.
"It is just too expensive to contemplate. So all we are saying,
unfortunately, is that they have to die."
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