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African Diary 

A UNC-Chapel Hill researcher's odyssey through the beauty and devastation of an AIDS-ravaged continent

Since July 2000, Dr. Charles van der Horst, professor of medicine and director of UNC-Chapel Hill's HIV/AIDS clinic, has made periodic visits to Africa to study and implement HIV/AIDS treatment practices there, continuing an almost two decades-long UNC presence on the continent. In return, the university has hosted African researchers, including Sam Phiri, a clinical officer from Malawi trained at UNC in the use of anti-retrovirals, and Henry Faluzi, lab director of Lilongwe Central Hospital, Malawi.

"In some African countries, where you have HIV-positive rates of 25 to 30 percent, the chances of a teenage boy dying of AIDS are over 60 percent," Dr. van der Horst says. "This could lead to the collapse of these countries." He hopes the UNC presence there will help turn the tide. The following are excerpts from his diary, dating from his most recent visit to Africa, from May 19-June 7.

May 19-21, Chapel Hill--Dulles Airport --Frankfurt--Johannesburg
Leaving for Africa, for my eighth trip in two years, fills me with excitement and sadness at the same time. While in the U.S., I miss the people I've been working with in Johannesburg, South Africa and Lilongwe, Malawi, a wonderful group of friends, a rainbow coalition committed to better government and better ways to study and treat people afflicted with HIV. What I haven't come to grips with yet is the sadness I feel in leaving my wife and two teenage daughters for extended periods. In preparation for the trip, I clean up my office, notify my lawyer, and say goodbyes as if I am not returning. Paranoia or realism? A mixture of both. Sept. 11 and the kidnapping death of a young physician in Johannesburg two weeks ago lends a new dimension to my travels.

A surprising number of UNC-Chapel Hill faculty members have been quietly working in Africa for more than 18 years. Frieda Behets, Ties Boerma, Myron Cohen, Susan Fiscus, Irving Hoffman, Francis Martinson, Steve Meshnick, Robin Ryder, and Annelies van Rie provide care and training and conduct clinical research with colleagues in Angola, Cameroon, the Democratic Republic of Congo, Madagascar, Malawi, and South Africa. I am the baby on the block. After 14 years of receiving National Institutes of Health (NIH) funding for human trials of new AIDS drugs in Chapel Hill, Greensboro and Charlotte, and receiving grants through the Ryan White Act to provide care for AIDS patients, I have chucked it all and started commuting to Johannesburg and Lilongwe. It was the faces of 24 million dying people in Africa that pulled me in the direction of this career change, the same kind of pull I felt back in the early '80s when I became an AIDS doctor. Lately, I'd begun to feel that my colleagues and I had accomplished much of what I had dreamed about in 1983 when the virus was first isolated: 15 different medications are approved for treatment of HIV and another dozen are in development. Between Duke University, UNC-Chapel Hill, and our collaborators, there are clinics for HIV care located within 60 miles of every patient in North Carolina, including the prisons. It was time to move on to Africa.

A member of my staff picks me up at the Chapel Hill High School on Sunday, May 19, at 5 p.m., just after the curtain closes on my daughter's dance performance. After quick hugs I begin a three-flight, two-night, 36-hour trip through Washington and Frankfurt to Joburg, as the locals call Johannesburg. On the last leg of the flight, I watch the sun rise, the deep purple blue of the heavens transformed gradually at the horizon to a white line, where this immense continent meets the endless sky. Haze in the distance turns into the brown and beige sand and rocks of the Kalahari Desert. Scraggly patches of trees give the desert the aspect of a teenager's bad shave. Slowly edging lower, we fly over the high veldt or plateau of Gauteng Province. The rainless winter air of the Southern Hemisphere has changed the verdant grass to gold. Mounds of earth rise out of the mist like a moonscape. Then the city itself appears, a cluster of skyscrapers gleaming pink in the dawn light, jutting Oz-like out of the plateau. Unlike the mythical Oz, though, downtown Joburg is a warren of half-empty run-down skyscrapers, and the teeming poverty-stricken people in the streets, largely abandoned by business and government, who have fled to the barbed-wire security of Sandton and other suburbs.

Black faces are everywhere. Running the airline, the customs and the bank, they are the government of the newly created Republic of South Africa. Only eight years old, a dynamic multiracial democracy is taking shape after more than 50 years of suppression by a white minority. Verwoerd, the former prime minister of South Africa, and his Afrikaner friends created the word and society of apartheid, virtually enslaving the population after World War II. Laws were written and passed, signs created and homes destroyed all in the name of keeping blacks separate from whites. The aftereffects continue to reverberate: It's overwhelming to contemplate the lack of electricity, homes, running water, schools and health care for the majority of South Africans, but the government continues to slowly chip away at the problems. For me, with an abiding interest in both politics and health care, I can't think of a more exciting, pulse-pounding place to be.

Dr. Ian Sanne, a young, towering blond internist and HIV specialist at Witwatersrand University, where I also have an appointment, picks me up at the airport. Ian began conducting pharmaceutical industry-funded clinical trials of antiretroviral drugs in South Africa in 1998, and has enrolled more patients with HIV on these life-saving medications than anyone in sub-Saharan Africa. The two of us, together with his colleagues in pediatrics and obstetrics, have been submitting grants to the NIH to train doctors and to study better, more cost-effective ways to treat HIV and tuberculosis in adults and children.

The needs are enormous. There are fewer than five infectious disease specialists in South Africa, a country with 15 percent of the global AIDS population. A viral load test, used to measure the quantity of virus in the blood, tops $50 in the U.S., a prohibitive figure for a continent where the annual health budget in most countries is less than one dollar per person.

During my visits to Johannesburg, I meet with individual investigators, review their research, edit drafts of papers and grant proposals and generally act as a cheerleader. In the United States we almost take it for granted that senior faculty at universities mentor junior faculty until their careers have taken off and they can stand on their own. There is no such tradition in South Africa. In South Africa there's also no history of government-supported research similar to the NIH. Most Americans don't realize that the vast improvement in care for patients in the U.S. is due in large part to funding provided by the NIH and research applications judged by the peer review system. Senior scientists do not get money just because they were great; they have to prove they are still the best every three to five years. This competitive structure leads to creative minds staying mentally in shape.

We're all waiting on tenterhooks as several grants are in review this month. As an academic whose salary is derived from "soft" money, these grants are important for me personally as well. When I decided to start working in Africa, I stepped off a cliff with only a tiny parachute strapped to my back, giving up my grants for HIV research and care in North Carolina to junior colleagues at UNC, with only one replacement grant. At times I feel I'm in a free fall.

Thursday, May 23, Johannesburg
The high incidence of violent crime in Johannesburg drives people to live behind high electric fences with a strong enough current to kill. I'm careful, when I leave the house, to electronically shut the gate and wait until I can physically see it shut. I generally do not wait at red lights in isolated areas at night; it's safer to risk the police than someone else. I'm also careful to always have a full tank of gas and a charged cell phone in case I get lost. It's a crazy existence, but I love the people and the work. Besides, the precautions are now second nature, as is driving on the left-hand side of the road.

With the headlights on, I speed into the outskirts of Joburg for the dawn swim practice with my team of South African college students and older farts like me. After practice and a breakfast of toasted muesli with granitina yoghurt, a bowl of fresh fruit including papaya, two capuccinos and a quick read of the Johannesburg Star, I go to work. Peter Kazembe, a pediatrician friend in Malawi, had e-mailed me en route to Africa, asking that I bring vials of intravenous cyclophosphamide for his children with Burkitt's lymphoma. Burkitt's is a type of cancer of lymph glands that occurs usually in children. Although the standard treatment regimen in the United States is a multidrug one, Peter achieves very good results with cyclophosphamide alone. The pharmacy at the central hospital in Lilongwe ran out of the drug, a common occurrence. So using money raised at our yearly fundraiser held at the Kenan Center in Chapel Hill, I'll buy the drug and carry it to Peter next Monday.

It's times like these I feel like paying homage to the electronic high-tech age. In the U.S. we take this all for granted, but cell phones and the Internet are transforming Africa. Many, even those of limited means, can buy a few minutes of cell phone time using prepaid cards. Doctors can access medical journals published in the United States and England. Not everyone here has computers, but the fact that a physician can send an e-mail from a remote part of Africa asking me to bring a life-saving drug is still something to pinch oneself about.

Ian and I drive to Chris Hani Baragwanath Hospital in Soweto, the largest in Africa at 5000 beds. Chris Hani was assassinated by an Afrikaner prior to the first election in 1994, when Mandela and the African National Congress (ANC) came to power. Soweto dwarfs Johannesburg, although it's a "township." In reality it has 5 million people and stretches for 20 kilometers, encompassing shacks and expensive homes.

A 12-story building on the campus of the hospital has been turned over to the AIDS treatment and research groups. If the NIH grants we have applied for come through, I'll have an office there for my quarterly trips. We take the elevator to the 12th floor to meet one of the pediatricians, Avye Violari, who runs the Prevention of Mother to Child Transmission (PMTCT) program at the hospital and its affiliated clinics throughout Soweto. On the surface, such a program seems simple: You offer voluntary counseling and testing (VCT) to pregnant women and those who are positive are given a single dose of an anti-HIV drug, nevirapine, to take when they go into labor, and then the child is given a single dose of nevirapine syrup shortly after delivery, which decreases transmission by 50 percent. The reality is that PMTCT is very complicated. Not all women want to be tested, so the program has to find out why. In Soweto, where the water quality is good, you need to offer formula powder to the mothers so they can avoid breastfeeding, which also leads to HIV transmission. You need to make sure they come back to deliver at a site where they can give the nevirapine syrup to the babies. The delivery room staff must check on the medical records for the HIV status of the mothers and give the syrup to the babies whenever they are delivered, morning, noon or night.

Avye and her boss, Glenda Gray, run one of the best programs in the world, with high acceptance of testing and uptake of nevirapine by mother and child. A steady stream of visitors comes from around Africa to learn the secrets of her success. Since I'm starting a similar program in Malawi, I take careful notes and ask lots of questions.

After this meeting I review the treatment of the adults seen in the clinic that morning with the junior doctors. One by one, Lucy Connell, Lorna Jenkin and Dinesh Dayel present the patients, telling me what their status was prior to starting medications to treat HIV, and then their response to treatment and any problems that had developed. All of these patients are being treated using funds from the European Union. The funding is not unlimited and we have to be cognizant of costs. The doctors at Bara have decided to treat the patients with ddI, d4T and efavirenz. BristolMyersSquibb, the maker of ddI and d4T, and Roche, who owns the marketing rights to efavirenz outside of the U.S., had negotiated a very reasonable "access price" for South Africa at $50 per month total, which is about what it costs to manufacture the drugs. They avoid using AZT and 3TC, manufactured by GlaxoSmithKline, because the price is $80 per month.

To the surprise of this American, the adherence rate of the patients in taking their medications and the efficacy of the drugs is the same or better among these patients than mine in North Carolina. When they asked one of the patients how many doses he missed in the last three days, he looked at them as if they were crazy: "You told me to take them so I did!" he said.

After clinic, Ian and I go back upstairs to a meeting with James McIntyre, one of the leading AIDS obstetric researchers in the world and overall director of the program. James and I have written a very large proposal to the NIH, which we hope to hear about this month. We discuss applying for another grant to help with training doctors, nurses and pharmacists in Africa in preparation for the introduction of antiretroviral (AIDS) drugs. The application is due in New York on June 3, so I'll be up late writing.

May 29, Lilongwe and Lake Malawi, Malawi
On each of my trips I spend time in South Africa and then fly onto Malawi, a two-hour flight north toward the equator. Malawi is a small, Portugal-sized country with over 10 million people, of whom almost one million are infected with HIV. Under the leadership of Mike Cohen, my boss, and Irving Hoffman, UNC's intrepid Director of International Operations, UNC has had an ever expanding treatment and care program in Lilongwe, the capital city, long before it became fashionable for American academics to work in Africa. More than 100 UNC Project doctors, nurses, and laboratory personnel provide care to literally hundreds of patients. Our group, led by Dr. Agnes Moses and David Jones, is only one part of the overall project. Dr. Moses, David and I have received funding from two sources for both a clinical research project and a service project targeting HIV-positive pregnant women. The Elizabeth Glaser Pediatric AIDS Foundation has funded us to enhance prenatal care, to offer VCT to pregnant women and the two-dose nevirapine regimen to prevent HIV transmission in Lilongwe, a program similar to the one in Johannesburg (PMTCT). The Centers for Disease Control (CDC) has given us provisional funding to study methods to decrease HIV from postpartum mothers to their babies through breast milk (UNC-CDC Safe Mother+Baby Project).

David, program manager of our PMTCT program in Malawi, late of Chapel Hill, currently of Lilongwe, heads out with me on the M1 Highway at 6:30 a.m. for Lake Malawi. We're going to the training session of the field investigators for our CDC project.

The sun is still low in the winter sky. Despite the early hour the earthen paths on either side of the two-lane blacktop road are filled with people walking or running to work or market. Huge bundles of charcoal in white plastic bags, pieces of wood, aluminum pots of water, bags of maize and rice sit on top of women's heads or stacked up four feet high on the backs of men's bicycles. Some carry huge golf umbrellas perched on shoulders for shade from the early sun. The women all wear chitenjes, wraparound skirts in a rainbow of colors beyond the palette of my imagination. People will walk hours each direction. Those with a few kwacha, the currency of Malawi, can get a ride on a minibus packed with riders or on an open Toyota truck, sitting on top of 10-foot high packages and bundles, dwarfing the truck cab. Many chew one-foot long pieces of green sugar cane, highly concentrated and overly sweet.

After gassing up the car at $50 a tank, we turn right onto the road towards Lake Malawi and Salima, 150 kilometers away. Driving in Malawi is an art. On the roads one always has a hand on the horn to warn stray goats or errant children. The roads are narrow, the car speeds high, and deaths frequent. On the way back from the lake, Amy Corneli, a UNC graduate student working on my project, passed an accident where the number two person from the European Union mission here, and her husband, were killed two weeks before they were to return home. In another accident this past rainy season, a friend of one of our staff members hit a woman and her child at dusk, and the baby died. Her agency paid for the funeral and bought food for the entire village. In the ultimate irony, the village chief wrote a note of thanks.

The rains have stopped a month early in Malawi, so the grass and maize stalks are all shriveled brown now. The landscape, which during my January trip was lush, with ripe patches of all the shades of Irish green, has turned prematurely brown, yellow and beige. The maize harvest was poor. Statia Norden, a nutritionist with the Peace Corps in Malawi, has railed against the mismanagement by the Malawian government. A series of disastrous decisions and corruption has led to a shortage of maize meal, the staple used to make nsima, Malawi grits. The government, and more specifically the previous Agricultural Minister, sold last year's crop to Zimbabwe, a former producer. Whether done at the behest of the International Monetary Fund (IMF) or not isn't clear. At the same time, one of the conditions of the debt forgiveness program was that they let the price of the maize meal float, which led to an immediate 40 percent increase in the price. Starvation looms large.

We pass through the hills into the lowlands as we get closer to the lake. Dedza Mountain, a gray rocky outcropping, is in the distance. Stopping at a long row of straw huts where wood carvings are for sale, we find Sam and Omar, two carvers who made gorgeous ebony bowls for the recipients of our UNC AIDS awards this year. Each man is short, wiry, with close shaved head and spotty teeth. They're eager to improve their business, and David has become their entrepreneurial advisor, buying them cameras so they can show pictures of their wood work, since it's too expensive to keep much in stock. He has also taken some work back to North Carolina to sell on consignment at One World Market.

We continue on to the fortuitously named Carolina Resort, a simple camp at the lake, turning onto a sandy narrow road and traveling through backyards, children waving and shouting "allo, allo" and occasionally "give me the money." The car bottom scrapes along the bumpy sand, to the barely functioning wire gate of the resort. David and Amy have picked the resort for our training of our field investigators since it's cheap, has no radio or television or big city nearby for distraction, and yet is a stunning location on the beach.

We're here at Lake Malawi with eight newly hired Malawian field investigators of the UNC-CDC Safe Mother+Baby Project. We're training for the formative research phase of this project. David and I go right into the session of the trainers. They have already been here for a week and a half, with an intervening weekend back home in Lilongwe. Ten in all, they were chosen through a rigorous process where they had to conduct a mock interview and witness one interview and take notes to determine their interviewing skills. They will conduct household visits and individual interviews with 60 HIV-positive women in Lilongwe. Moving around the room, each person quietly introduces him- or herself: Jacqueline, Sibongele, Justice, Janerose, Francis, Maxwell, Gift, Noel, Gibson and Lazarus.

The field investigators had visited a local clinic in Salima the previous day to practice interviewing and note taking. The session proceeds first to a general critique of the interviews by Beatrice Mtimuni, a nutrition professor at Bunda College of Agriculture and a consultant for our project, as well as by Amy Corneli, the local leader for this portion of the project. The discussion is lively and Amy is a master leader. Furiously taking notes, I listen with intensity to these vital issues. We discuss confidentiality and how to protect the clients being interviewed. Information on the data forms should have no identifiers of a particular patient, no names or addresses and no employer name. The irony is that in a country where one in four people in the cities is infected with HIV, no one acknowledges their HIV status and no one dies from AIDS.

We discuss whether or not it's OK to give the patient advice, since it might interfere with the interview. Dr. Moses, a graduate of the college of medicine at the University of Malawi, points out that "In Lilongwe, most of the respondents will have a high health literacy rate, so it's better to leave the interview at a neutral point, since your advice may interfere with health seeking behavior; only emphasize what the client has already said if you know the information to be correct." The consensus is that you should not give any advice until the end of the interview, and certainly not unless you have the expertise.

The interviewers start relating anecdotes illustrating the complexity of the interview process. One client tried to test an interviewer's knowledge by saying, "I put water in a condom to see if it leaked and after several days there were worms in it. Why is that?" After it was explained that the water was dirty, the respondent said, "Good answer." Another client, when asked, "Why did you choose to give birth at home?" responded, "I am not comfortable answering." Beatrice says that when she asked one woman, "Why did you stop breast-feeding?" the woman answered, "Because I was pregnant again and the milk is no longer for this child, it is for the child I am expecting."

After our session the group asks me to give a talk about HIV treatment in general and the proposed CDC research project, which would start next year. Clinical research can involve three components: use of medications to treat humans, randomization--or the equivalent of a coin toss--used to determine what treatment the patient receives, and a control group or standard treatment group. My colleagues at UNC, the CDC and in Malawi are currently deciding the best way to test whether treating either the mother or the HIV-negative breast-feeding babies during the period of breast-feeding will prevent transmission to the babies. After I sketch out our tentative plans, the field investigators pepper me with questions about the rationale for stopping therapy after the women stop breast-feeding and the rationale for the control or no-treatment group, and what viral resistance is. With a rapt audience, I explain that mothers with low CD4 counts, signifying AIDS, would be treated for HIV and not randomized to a control arm, and that recent data shows that treatment of people with intact immune systems or high CD4 counts may not help them in the long run, given the toxicity of the drugs and the possible development of resistance to the medications. Also, the HIV-negative babies will be absorbing the drugs the mother takes through the breast milk with unknown potential toxicity. Finally, I tell them we were intending to treat the mothers with low CD4 counts until they fail their regimen, no matter how long. The discussion is an exhilarating give and take and ends on a note full of hope for everyone in the room.

Jacqueline Kanjira, our outreach coordinator, Dr. Moses, David and I meet to review all the progress to date for both the research and prevention programs. We discuss the feasibility of using directly observed therapy, or DOT, to make certain that patients are getting all their doses. This is how TB therapy is given in many places around the world, including Malawi, usually for the first two months. It is very expensive in personnel costs. Since we are planning to enroll only 400 mothers on triple drug therapy at four different health centers in Lilongwe, we could have people visit them using bicycles and some could actually come to the clinic to get their doses. Also, each village has a government funded health surveillance assistant who is supposed to live in the district. We could have the patient sign that they took the medication. We could give the nutritional supplement there as well.

We also discussed our treatment project, Call to Action, funded by the Elizabeth Glaser Pediatric AIDS Foundation. This program conducts voluntary testing and counseling of pregnant women at the antenatal clinic at Bottom Hospital; then in the third trimester we give the mothers a 200 milligram tablet of nevirapine to take at home when labor starts. When the mothers come to the hospital, we'll check their status and give the babies nevirapine syrup. To diagnose HIV in a baby you need to actually measure if the virus is present, which costs $35. You cannot rely on the cheaper antibody test, because the antibodies in the baby have been transmitted from the mother and persist for longer than 12 months. When we designed the program and the consent form we specified that we were going to stick the babies heels to get a drop of blood to put on filter paper at age six weeks. With this we can test for the presence of virus at any time.

Dr. Moses and Jacqueline said some of the mothers enrolled on a research study who were given a few kwacha for travel expenses thought we were buying their blood to take to the United States and that the amount we are taking is not really the amount we are showing in the tube. If the mothers are complaining about the five to seven milliliters we're taking for that study, how much more will they object to the 50 milliliters we'll need for my big project next year! We decide to hire a local cartoonist from one of the newspapers to make a giant cartoon of a person illustrating how much blood is in the body and how much we are taking, as well as a poster illustrating what we are doing with each tube of blood and how many teaspoons are in each tube.

"Most of these issues go back to the old days, to the 1980s," explains Dr. Moses. "The people know anemia. They know about the white vehicle with the white man in it and were taught as children to run away because they will take your blood." On the other hand, they are perfectly comfortable with the traditional healer making cuts and applying traditional medicines.

Later, at sunset, I'm sitting at a yellow-painted wooden table looking at Lake Malawi. On my right, the bay curves around so that across the water I can see the low mountains of Cape Maclear rising dark out of the mist, green trees still reflecting the setting sun and radio towers. The sky is studded with strands of clouds stretching to the horizon, with an intense array of pink and orange radiating from the sun. To the left another point, and across the water a dark ridge of mountains undulating without any sharp or high peaks. Here the coast across the water is Malawi. Further north, Mozambique and Tanzania. Far out I can see a tiny sliver of black, low in the water with a figure in silhouette, hard to make out, a fisherman looking for what at sunset? The sky above the dark mountains is a low bank of smoky gray, then purple pink in the setting sun, moving across to scudding white and orange-tinged clouds on the left into heaped-up cumulus. A small green and white rocky island is rising out: Monitor Island, where the monitor lizards live. The birds are feeding on the bugs and malarial mosquitoes coming out at night. A solitary fisher sits on a pole, black, white and red. Tiny pearls of light begin to pop on across the shore. The lake stretches the entire length of the country and is said to be the "year" lake, 52 kilometers wide and 365 kilometers long, as well as half a mile deep in parts. After dark a string of flickering lights can be seen across the water as fishermen shine torches to attract the fish to their nets.

May 31, Lake Malawi
David and I return to the lake for the closing ceremony to mark the "graduation" of the field investigators from their training. Jacqueline and Amy Corneli, as two trainers, make a speech, and so do I. I speak of the crisis HIV has brought to Malawi and how important formative research is to developing strategies for both care and research. I tell them I am honored that they are working with UNC to help get these answers that will benefit Malawi.

June 1, Lilongwe
Mina Hosseinipour, a young UNC infectious diseases faculty member, is currently living in Lilongwe at our residence and is hosting the Saturday morning Hash Run. Although it's only 6:30 a.m., about 10 people have gathered on our front porch. This was a serious run as opposed to the original British colonial version, where people try to find their way through the jungle with beer stations (or something stronger) scattered along the way. I ran the farthest I've ever run, 13.8 kilometers, but not as far as most of these folks, and by the end my gait looked like speed walking. While the others ran another 14 kilometers, I cooked up scrambled eggs and hash browns and bacon for the meat eaters (I abstained). Afterwards, I watched the end of the Ireland vs. Cameroon soccer match. Everybody watches the games in Africa. Most of the Africans want an African team to win, but the most important thing for them is to see good "football." They were really angry with the FIFA (soccer federation) vote last year to hold the World Cup in Korea/Japan and not in South Africa.

June 5, On the road to Blantyre, Malawi
Justin, tall dark and handsome with a buzz cut and a lyrical voice, is the taxi driver. We head south for Blantyre, the commercial capital of Malawi, at 8 a.m. The winter sky is crowded with thick, gray clouds and occasional raindrops hit the windshield. Hand on horn, Justin expertly weaves around scratched blue buses piled with mattresses, bags of rice and maize, and red, yellow and blue tottering minibuses and four-wheel drive vehicles all belching thick black burnt-oil smoke. At the last minute, David had decided to stay in Lilongwe to get the different grant accounts straightened out, so I hired a taxi. A 20-year-old, battered brown Nissan Sentra that had, many owners before, been driven by the American ambassador, it wheezed and rattled, required Justin to touch wires together to get the window to open, and amazingly made the 300 kilometer trip with me in one piece. Justin kept me entertained during the 3-1/2 hours each way. His wife had died in March, and he was raising his 4-year-old son Justin Junior himself. His dream was to own his own taxi. We launch into a discussion of politics for the next three hours.

The politics in African countries are just as exciting and of greater import than U.S. politics. Malawi has a president, Bakili Muluzi, and a parliament. Muluzi is nearing the end of his two terms, the first democratically elected president after the dictatorship of Kamuzu Banda, who had led Malawi to independence. President Muluzi's United Democratic Party (UDP) wants to amend the constitution to abolish term limits. Denmark has already closed its embassy and withdrawn its ambassador in protest. The middle class--or at least the members of it whom I had taken out to dinner the night before--are worried that he will destroy the progress that has been made. Justin asks, "Why can't he be like Mandela? The man was in prison, becomes president, leads his land into democracy and then steps down. Everyone respects him, listens to him. Muluzi should do the same."

The road climbs and winds its way into the mountains, bare of most trees, with gray thrusting stone on the sides and bald rounded peaks. At frequent intervals, like African sentries, 4-foot tall used bags stuffed with charcoal chunks stand amid a pile of supporting brown rocks like feet, with black pieces rising over the top of the bag like hair. All for sale, but where are the salesmen? Tomatoes, potatoes and oranges in buckets and wicker flat baskets are sitting in lines along the road. When we stop to check on the price, women or men run up out of nowhere to bargain with us.

On the way back, Justin asks me about the HIV/AIDS test. I ask him if he ever has had a test.
"Oh no, not now!"
"Why not?"
"I want to build up my bank account. If I am positive I want to sit down."
"You know, they have the medicines in Lilongwe now."
"How much?"
"2,500 kwacha each month."
"Sure, and you feel well and can keep working."

Justin takes in the information without revealing whether or not he will act on it.

June 7-8 Lilongwe, Johannesburg--Frankfurt--Dulles Airport--Chapel Hill
At five in the morning at the UNC residence in Lilongwe, snuggled under two blankets in blue flannels, my eyes open with the roosters and the anticipation of seeing my family. My pulse is pounding. After giving David a going away gift, he drops me off at Bottom Hospital in downtown Lilongwe, where our antenatal clinic is located along with our prevention of mother to child transmission project.

The clients seeking medical care in Malawi arrive early and all at once. A huge stream of humanity hits the paths, dirt roads and highways soon after dawn everyday, moving to their jobs, the market or the clinics, using whatever method they can afford to get there, usually their feet, often bare. The women steadily fill up the long, cold cement benches situated under overhangs of the clinic buildings, starting closest to the building. Women for antenatal care sit on the right and those for the family planning clinic or the under-five clinic on the left. More than 120 women have shown up at the antenatal clinic this morning, almost everyone with a child in her arms. No two women are dressed alike. Many have thick sweaters to ward off the cold morning air. Yellow, black, brown, pink, red, green, Carolina blue, all in bold large patterns and all women with a chitenje around their waists. Many have babies on their backs in a sling trussed around their bosoms. It's difficult for me to assess the age of the children as the rates of stunting, low height for age--a measure of chronic malnutrition--can exceed 40 percent in parts of Malawi.

Promptly at 7:45 a.m., the wooden doors still closed, Esmie Kamanga, a nurse who works for me, begins "sensitization." Dressed in a white dress, Esmie is short and solid. All bow their heads in prayer first, often with Esmie calling on one of the patients to start. She has a lilting voice, her face fixed in a cherubic smile, asking ironic questions as she both teaches and prompts the women with questions. The topics range from prenatal care to family planning to what is research and why that is different from care. A year ago, in the early days of the research project, the nurses had also included HIV testing in the "sensitization" process, but half of the women just stood up and walked away. So now the list of topics are blander. They do describe the new standard of care for prevention of transmission by mentioning only the pill they must take when they go into labor and how important it is for the women to come to the hospital for delivery so that their baby can get medicine too. A little subtle for my taste, talking about nevirapine in anonymous and isolated terms without mentioning HIV, but at this point it's necessary. You can often achieve what you want by traveling on other than straight paths.

The women, usually quiet and shy, start answering the questions and all respond simultaneously with "Hmmm" or "Eh," the Malawi equivalent of "uh huh" or "you go, girl." Every now and then Gertrude Mwale, my other nurse, chimes in from the other end of the aisle. My lack of proficiency in Chichewe hinders comprehension, but Dr. Moses gamely lets me know every now and then what is happening. Then Esmie and Gertrude start clapping, followed by singing a call-response song. This tradition, used to sing in churches, is the standard format to emphasize key health messages, both at clinics and in the villages. For family planning the song says, "How am I going to take care of all these children? How am I going to do all that washing?" Gertrude and Esmie start dancing to the tune, swaying their hips side to side, moving in the aisle, still clapping. Two or three other women, the braver clients, join them. The big azunga (me) stands up in the rear and dances and sings as well, without the grace or the hips.

At the end, the women race for the door of the clinic, pushing each other and me aside to get in line. Some women are returning for study visits for the Chorioamnionitis or "Chorio" study, whose purpose is to see if empiric treatment of asymptomatic inflammation of the amniotic sac will decrease HIV transmission and perinatal problems for mother and child. More than 200 women have been enrolled in the last 10 months. Another group is here for their first visits; they are the group the sensitization session was aimed at, to educate them about pregnancy and to explain that, for those who are between four and six months of pregnancy, the Chorio research study is available. The final group are people who are returning for their HIV test results, either done in preparation for entry into the Chorio study or the HIV prevention or PMTCT program.

The great success of this poorest of the poor countries is that over 90 percent of women in Malawi have at least one prenatal visit, a figure that exceeds that in many parts of the U.S. That makes this population an ideal target for voluntary testing and counseling for HIV infection. The goals are for every woman to be tested and get the medication. The results of our first 2 months are promising. After the sensitization, we break the women into small groups of 10, either for my program or the Chorio study. There the facts about HIV, HIV testing and transmission are broached. Then the women have one-on-one counseling by Esmie and Gertrude and their blood is drawn. Seventy-nine percent of the women hearing the small group talk agree to be tested. Of those who are positive, 50 percent do not return for the results. The nurses say some do not want to know and some are afraid of their husbands. Some feel that the test result itself means death. No result, no death. One woman returned the next day saying, "I spoke with my husband and he does not want me to have this test. He does not want to die and he wants me to get my blood back." Ninety percent of the HIV-negative women return for the result, as if people have already self-selected themselves into groups who know instinctively that they are infected. Nonetheless, for both the PMTCT program and the Chorio study we have tracing nurses, whose job is to go and find the women. Many of the women show up at other clinics so we can talk to them about returning to participate in the program. We are close to having 100 percent of the women being found for both programs, a shining light in this region.

The clinic we work in consists of just six small rooms, a file room and a lab in a red brick building with two story ceilings. When we decided to start the PMTCT program we took over the nurses break room (after bribing them with an electric kettle) and built a wall in the middle, creating a miniscule space filled with the desk, examination table and two chairs. Since there is only one group counseling room in this small building and it's used by the Chorio group, our PMTCT folks open both doors to the counseling rooms and the hallway to create a very cramped group counseling space. We are waiting to hear from the Centers for Disease Control about extending our breast milk intervention research study to four years, as well as about granting permission to renovate space to create an annex with eight larger exam rooms, a laboratory for blood counts and CD4 counts, and a larger group counseling room.

After a flurry of goodbyes to the clinic staff I head to Lilongwe Central Hospital to say goodbye to my friend, Peter Kazembe. We discuss our joint research and care projects for the future, including the small library we're building for students and other trainees outside his office using some of our UNC fundraiser money. He gives me two CDs of Malawian music. Then back to the UNC office for a quick hug goodbye with Dr. Moses and David.

The long flights home allow for a Zen-like state of writing and contemplation. In reflecting on the previous three weeks of 12-hour days and nightly dinners with colleagues and staff, I feel contented with my bi-continental life. Of course there are still endless "to do" lists on scraps of paper, my notebook and Palm Pilot, as well as constant worries about funding, health of staff, and governmental roadblocks. My old technique of the past 20 years comes through to settle me, though, namely focusing on what gives me the greatest joy: providing care to patients here, and helping babies to live free of HIV. Every woman we test, we give potential empowering knowledge, whatever the result.

In Dulles Airport I call my wife Laura, and we talk for the first time in three weeks. Choked up, I recount some of my stories and catch up with hers and the girls.

June 14, Chapel Hill
My project officer from the CDC calls me at my office. The extension funding is on, and the construction for the annex for our breast milk intervention research center can proceed. I e-mail my colleagues with the good news. Looks like I'll be returning often to Africa, for some time to come. EndBlock

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