Ich habe von eingen Seiten gehört, dass es ein Problem ist, wenn ich auf Englisch schreibe. Das tut mir leid ;-) ich werde trotzdem hier den Englischen Projektbericht des EAWM veröffentlichen. Also, was tut sich in Bulongwa und mit PIUMA?

Viel Neues und trotzdem es so lange dauert, viele Zeichen der Hoffnung für die Menschen mit HIV/AIDS in Bulongwa und Makete:


PIUMA auf dem Weg zur Selbständigkeit

Immer wieder habe ich vom Kampf PIUMA’s um eine bessere Versorgung der Menschen die mit HIV/AIDS leben, berichtet. Diese Anstrengungen wurden wiederholt durch eine bis in die Grundfeste korrupte lokale Lutherische Kirche, durch die fehlende Solidarität mit den geschädigten Armen in Makete seitens der in Spendengeldskandalen verwickelten Missionen aus Europa, sowie durch korrupte lokale Beamte, erschwert. Es gibt aber Fortschritte, gegen alle strukturellen Widrigkeiten.

Der Premierminister hat nun über Vicky/BBC PIUMA kontaktiert und seine Unterstützung beim Kampf gegen HIV/AIDS angekündigt, er würde Anliegen nun direkt und persönlich empfangen. Es wurde im Rahmen der Gespräche auch klar, dass der Premier durch Kirchenvertreter über die belegten Finanzskandale und die Fortschritte bei deren Bekämpfung falsch informiert wurde und dass es vor allem durch die Polizei zu Menschenrechtsvertretungen (Jackson und Reporter ins Gefängnis) gekommen war.

Bevor der Premier Stellung bezogen hat, waren 4 PIUMA Mitglieder nach Dar es Salaam gefahren und hatten in Pressekonferenzen von Ihrem Leid, dem Sterben und der Korruption um die HIV/AIDS und Entwicklungsgelder berichtet. Aizack war laut und deutlich zweimal auf der BBC. Die meisten Zeitungen hatten PIUMA boykottiert, nachdem der Makete Parlamentarier mit Byron (!) angeblich von Redaktion zu Redaktion gepilgert war und erkärt hatte, dass PIUMA von Ausländern finanziert wäre, die das Gold (Bodenschätze) in Makete ausbeuten wollen... und die Kirche zerstören wollen? Aber solche Stimmen nehmen ab und die größte Tanzanische Wochenzeitung titelte "Makete - Ihr seid so korrupt, dass Ihr Euch schon vor den Armen fürchtet"

Wie berichtet, wurden die moderne CD4 Counter der Firma Partec aus Münster, die zur HIV/AIDS Behandlung notwendig sind, stillgelegt und durch Kirchenleitung und den Gesundheitsminister durch nicht funktionierende Konkurrenzprodukte (BD - FACSCount) ersetzt, die mittlerweile in vielen Ländern wegen unfairer monopolistischer Marktbeherrschung unter Kritik stehen. Die monatelange landesweite Presseberichterstattung, in der auch PIUMA und der EAWM genannt wurden, haben dazu geführt, dass eine staatliche Untersuchungskommission ins Leben gerufen wurde, die den Korruptionsverdacht untersuchte und die Unregelmäßigkeiten bei Beschaffungsvorgängen um HIV/AIDS Ausrüstungen (cd4 Counter und HIV Tests) bestätigte. Mittlerweile wurde im Gesundheitsministerium Spitzenbeamte zur Verantwortung gezogen, beziehungsweise entlassen und es wird erwartet, dass die Geräte bald wieder in Betrieb genommen werden können. Vor einigen Tagen war in Bulongwa die Staatspolizei zu Besuch und hat die Maschinen in der Obhut der Gruppe begutachtet und gemeint, dass diese sehr bald wieder in Betrieb genommen werden müssen.

Alles in allem ein Beispiel für tödliche Korruption gefördert durch Spendengelder und fehlende Kontrolle und die Wichtigkeit der freien Presse und auch ein Erfolg des Aufschreis von PIUMA. Ein gutes Gesundheits- und Sozialsystem funktionieren nur auf dem Boden von gerechten Strukturen, aufgrund von Ehrlichkeit und unter Einbeziehung der Community - wenn das nicht gegeben ist, braucht es Kontrolle!

In die gleiche Kerbe der Förderung von „accountability“ und des richtigen Gebrauchs der Mittel schlagen die Ausarbeitung und der Beschluss eines Ethikkodes durch die Selbsthilfegruppe PIUMA. Der Ethikkode wurde auch auf http://www.highlandshope.com/ veröffentlicht und mittlerweile in einer Diplomarbeit begutachtet.

Angesichts des fahrlässigen Umganges mit Spendengelderen durch die Geber aus dem Norden und des machtvollen, reichen Lebens, das jenen ermöglicht wurde, die unkontrolliert Zugang zu Spendengeldern hatten, finden es der EAWM als eine besondere Leistung der Solidarität und der Reife von Menschen, die krank sind und im Jahr nur wenige Euro in der Hand halten, dass sie sich verpflichten mit Mitteln sparsam umzugehen, in Solidarität zu Teilen, gemeinsam für ihre Rechte zu kämpfen und an einer Zukunft ohne AIDS und Korruption zu arbeiten. Sicherlich noch ein langer Weg, aber ein Anfang, gegen alle schlechten Beispiele der unkontrollierten Korruption der Eliten und der kirchlichen Werke aus Europa und den USA.

Der neuen Tansanischen Regierung ist in ihrem Kampf gegen Korruption jedenfalls zu gratulieren. Einstweilen.

Von Tansanischen Wirtschaftsfachleuten und Entwicklungsexperten wurde gemeinsam mit PIUMA ein Seminar abgehalten, bei dem es um Buchführung, Leadership, sowie Selbsthilfeprojekte und deren Planung ging. 82 Teilnehmer waren mit dabei. Die Statuten der Organisation wurden diskutiert und die Mitglieder wurden über verfassungsmäßige Rechte und die Menschenrechte informiert. Bildung und Information als Grundvoraussetzung für Selbständigkeit!

Immer wieder wurde angekündigt, dass PIUMA die Lizenz zum Betreiben eines eigenen Testzentrums und einer eigenen Klinik bekommt. Es sieht so aus, wie wenn dieses Vorhaben im Gesundheitsministerium wieder und wieder verzögert wurde (Zusagen wurden gemacht und zurückgezogen, Briefe verschwanden, Unterstützer und Journalisten wurden bedroht…).

Erst nachdem PIUMA Mitglieder in Dar es Salaam ihre Pressekonferenz gaben und die Probleme um CD4 Maschinen und Korruption um HIV/AIDS Gelder und Projekte in Staat und Kirche thematisiert wurden und die Interviews ausgestrahlt wurden, berichtet PIUMA, dass der Bezirkshauptmann ein sehr gutes Gebäude zur Verfügung gestellt habe, in dem die Gruppe nun das Testzentrum betreiben soll und dort sollen möglichst bald auch die lebenswichtigen Labormaschinen wieder in Betrieb genommen werden – wir hoffen, es stimmt!

(Als gebrannte Kinder, die immer wieder vertröstet wurden wagen wir zu hoffen und nicht zu jubeln, dass das Sterben wieder aufhört). Hätten die Missionswerke laut Ihre Stimme gegen die Korruption erhoben, anstatt diese zu finanzieren, dann wäre die Sache schon lange erledigt. Der angeblich abgesetzte Bischof hat wieder ein Auto verkauft (ein spendengeldbezahltes Auto) und das Geld ausgegeben... das neue Auto ist angeblich schon unterwegs.

Das Gebäude wurde jedenfalls geputzt und gesäubert, ist sehr schön und wurde vor Jahren von dänischen Entwicklungshelfern gebaut und dem Distrikt übergeben, nachdem ein lokales Forstprojekt abgeschlossen wurde.

Das Auto für die Fahrten in die Dörfer, um auch dort HIV Tests durchzuführen und letztlich auch die Therapie zu den Menschen zu bringen, soll nun endgültig gekauft werden. Die Kostenvoranschläge liegen vor und es gibt noch technische Abstimmungen.

Es war ein besonders schönes Erlebnis, dass sich eine Kanadische Graphik- und „branding“ Firma kostenlos der Entwicklung eines neuen Logos für PIUMA angenommen hat. Entstanden ist nach regem Austausch ein Löwe der auf dem Red Ribbon ("AIDS - Schleife") einherschreitet.

„PIUMA ist stark wie ein Löwe“ ist ein bekannter Slogan der Menschen mit HIV/AIDS in Makete und ein Kommentar war: „Ihr habt unsere Gedanken gelesen, das ist PIUMA, dieses Symbol IST PIUMA“.

Ein neuer Gedanke, die „Kranken“ und Armen sind stark wie die Löwen und nicht Bettler, die auf unsere Almosen warten. Auch wenn es noch ein wenig Hilfe braucht für das Auto und die kleinen Gehälter der Schwestern. (die Kontonummer gibt es unter eawm@magnet.at und ich bin fast 100% sicher, dass alles Geld ankommt und dazu führen wird, dass die Klinik bald unterwegs ist und die Menschen nicht mehr 70 km zum Testen und zur Behandlung gehen müssen, PIUMA wird sich aufmachen Vorbeugung und Therapie in die Dörfer zu bringen).

Der Löwe ist in der Tansanischen Fabelwelt ein wiedergeborener Mensch, der in seinem früheren Leben von anderen schlecht/unrecht behandelt wurde.

Das Logo findet sich auf http://www.higlandshope.com/ und Royal aus Kanada wird nun 4 Tage nach Wien kommen auf seinem Weg nach Tanzania, wo er an einem Solidaritätsmarsch in Makete teilnehmen wird, da wird er auch die Kangas (weibliche Bekleidung) mitnehmen können, die Schüler in Wien gemacht haben... aber das ist eine andere Geschichte und von der berichte ich das nächste mal....

Was tun wir, wenn PIUMA wirklich den Auftrag bekommt, im ganzen Distrikt zu arbeiten? Auch wenn die Regierung dann die Gehälter übernehmen würde, für das Gesundheitspersonal - Barnabas, der Labortechniker ist schon wieder auf den Weg nach Bulongwa - dann wird der EAWM und PIUMA wohl Unterstützung brauchen, Geld, Menschen und Mut... dann behandeln wir nicht hunderte, dann werden es tausende sein und mit dem besten Labor der Welt auf Rädern.

Und geleitet wird das Ganze dann von PIUMA - von den Patienten stark wie Löwen - und in der best möglichen Qualität, dann werde ich wieder gut schlafen können!

The Role of the Internet

Internet satellite backbone was used since late 2005 in order to improve communication between the program and the National AIDS Control Program and other partners.

This tool turned out to be very useful in order to:
• Transfer required data about clinic progress to the NACP in a timely fashion;

• Gain access to state of the art medical knowledge and to exchange with colleagues throughout the world on medical matters;

• Have access to the latest HIV/AIDS information from all over the world;

• Communicate accounts and reports to the donors;


• Overcome the policy of hiding information from the Have Nots which was used to keep the “cooperative corruption” between Elites (corrupt ELCT representatives) and Do-Gooders (financing partner missions) going;

• Get information about secondary school results to students.


Our experience is that, internet is a powerful and cost effective means to close the information gap between informed Elites and Do-Gooders who try to keep information away from the suffering Have Nots!
Without access to internet, the protest against the thieves in the church and the government would not have emerged so quickly and the situation would be even further from change and liberation.
Blogs were used to inform the donors and automatically developed into a control mechanism for the program as interested donors started asking and communicating.

www.highlandshope.com
www.mbogela.blogspot.com
www.rainerbrandl.blogspot.com
www.gerhardraxendorfer.blogspot.com
www.judithschnabler.blogspot.com



Technology: CD4 Counters - a business opportunity for Elites?

“A Dar es Salaam businessman with exclusive rights to supply HIV test kits – at hiked prices – is behaving like a gagged man against press probes,... ...Rajan’s Biocare has supplied the ministry with chemistry analyzers, hematology analyzers and FACS Count cd4 count machines which are said to be costly because they use expensive reagents.”
Partec’s CD4 counters were successfully used for about 18 months in the program. One counter that was donated to PIUMA was capable of doing CD4% counts (necessary to treat children). Later on these CYFLOW Counters were replaced at BLH by a FACSCount (Becton and Dickenson) that ended up not working most of the time and not easily able to provide results for children .
The Elites in the government and the church management were acting against ministerial regulations of their own country and against the human rights of PLWHA by impairing a clinic which was regularly providing CD4 counts according the requirements of the NACP.
It is a truism of economics that higher prices result after decisions that lead to market domination by a single product because of a lack of competition. Following market monopolization by Becton and Dickenson, in some cases the prices for reagents for the FACSCount was reportedly 25 times higher than those of other manufacturers or the announced minimum price .
A CYFLOW CD4 counter can run on a car battery or a solar panel and because of its robustness and portability it can be operated in a rural health centre or in a car by one trained person – its handling is rather simple. Mobile CD4 laboratories are already successfully used in Nigeria. In December 2005 a price guarantee of 10 years was offered to Tanzania for CYFLOW Counters and reagents.
Media reports in Tanzania claim that civil servants and university employees who are leading assessments of health products for use in Tanzania have close ties with businessmen dealing with the import of such products . It is said that they were promoting certain products while denying others access to the market. The result of these odious relationships is that a lot of money is spent for overpriced, sometimes lower quality, equipment that does not work well in resource-limited rural settings. Fewer CD4 counts are done and patients are kept from life saving treatment. Elites are indirectly promoting misery and death among the Have Nots for personal gain, while Do-gooders keep dumb in order “not to interfere in another country and to respect the local government”



Current president of Tanzania Jakaya Mrisho Kikwete received an explanation
about PIUMA’s Partec technology
during his campaign visit in December 2005.
His message was,
“Let’s develop partnerships.”

(PIUMA is in possession of two functioning cd4 count machines
that could be used in a mobile clinic
bringing monitoring and treatment to the people)


The counters are lying idle in Bulongwa as trained staff were locked out by the church
and equipment was confiscated and held for several months by people
who do not know how to run and maintain it



Theft and Systemic Corruption: The International Alliance

“ELCT TRICKSTERS “EAT” 270 MILLION DONOR SHILLINGS
…The Tricksters of the Evangelical Lutheran Church of Tanzania… …Diocese of Makete District in Iringa Region are alleged to have “eaten” more than 270 million shillings money donated… ...Institutions whose money has been “eaten” (stolen) include the Headquarters of the Diocese… ... Audit investigation conducted at the end of last year (2005)… … its finding presented to the Diocese Bishop Shadrack Manyiewa, shows that 272, 554, 937 have been stolen… …The Bulongwa Lutheran Hospital… ... more than 176,682,917 shillings has not been accounted for...”
ELCT and LMC and most of the Donors who invested a lot of money in the SCD and in Makete did not react in a timely fashion according to local laws and national and international conventions on human rights and the felonies within the church structures were not officially announced to the authorities by them.
“It may be worthy noting that misappropriation of funds did indeed occur at Bulongwa Lutheran Hospital and Makete Development Foundation” . This sentence by the presiding ELCT bishop was found only after the frauds were communicated to the public via the media by representatives of the local community . The existence of earlier internal SCD/ELCT audit reports indicating fraud make one wonder why this did not raise eyebrows among the donors or in the ELCT/LMC many years before. Instead ELCT, LMC and some overseas missions actively spread misinformation in their reports, newspaper articles and mail outs regarding the situation with SCD/ELCT.
Other partners in this informal international alliance of elites are obviously civil servants at the Ministry of Health with their ties to dealers of the FACScount. The MoH is currently involved in a procurement scandal concerning CD4 counters and HIV Tests which directly led to the suffering of the Have Nots in Bulongwa/Makete and throughout the country.
The Makete and Iringa police unlawfully detained Jackson Mbogela, the project coordinator of EAWM, for 4 days and did the same with a journalist named Edwin David after they became publicly vocal about the scandals in Makete.
EAWM is deeply concerned that foreign donors to ELCT/SCD have not at any time admitted openly their complicity and responsibility for this corruption, rather they are obviously attempting to maintain financial support for a Diocese where felonies are ignored with and no new accountability structure can be seen on the horizon. At no time in this regrettable story did donor missions find public words of solidarity with the betrayed Have Nots. EAWM believes that some the ELCT, the donor missions and some government officials have become structural allies in denying the PLWHA a better care and rapid scaling up of access to life-saving treatment.

The Media and the Poor: The Flow of Information

More than 20 newspaper articles appeared in different papers in the national English and Kiswahili press connected to the plight of the Have Nots in Makete. Several Radio Reports were broadcasted by BBC English and Kiswahili Services and by Radio Free Africa.
At the beginning of the program, the media was reporting about successes but increasingly corruption, theft and attacks against patients and the program were made known to the public.
The media were dealing with People living with HIV/AIDS publicly disclosing their HIV status, the plight of children and in particular orphans leading households, the theft of donor monies in Makete, the lock-out of the EAWM program, statements and letters from local community representatives concerning the fraud in church and district, the visit of the Minister of Health and the visit of the Prime Minister and, last but not least, the irregularities and the involvement of corrupt Elites concerning procurement of cd4 machines.
Makete was chosen as one of the sites for a country wide BBC/UNDP media training program for journalists, NGOs and political leaders in preparation for the 2005 presidential election in Tanzania . PLWHA were interviewed and their contributions were used to produce radio features and newspaper articles. Strangely, some pieces with the Lutheran Bishop of SCD admitting the theft of funds mysteriously were lost. A BBC radio interview with the Bishop was broadcast but only after more than a year’s delay .
The media played a core role in informing the public about the human right abuses and theft in Makete and helped Have Nots, local citizens and supporters to air their grievances. The public reaction and resulting visits of leaders taught them that they have a voice and the right to speak out. This human right is obviously not respected by the ELCT and elements of the local government. ELCT complained about the nationwide publicity though the sad facts were known to them for years. Up to this time, neither the ELCT nor its partners have announced efforts that have resulted in any positive effect on the plight of the Have Nots . The Elites and Do-Gooders from North and South built an alliance against the Have Nots in Makete and even though they themselves claim to believe that without free speech and a free media it is very difficult to put development on track, in practice they used their money and connections to blame the media messengers and the poor instead of cleaning their own house of corruption and criminality.
By actively feeding rumours that foreign staff and EAWM were seeking the resignation of the local bishop in an attempt to damage the church, the benefitting Elites and Do- Gooders tried to shift attention away from the voices of ordinary Tanzanians who were indeed demanding the resignation of the bishop because of documented fraud and incompetence.
This elite strategy led to threats and police harassment of journalists and, probably, to the violent lock out of the clinic.

Special Treatment Situations

Tuberculosis

Tuberculosis was treated in harmony with the National TB program and several cases of TB as part of an immune recovery syndrome occurred. Sputum smear negative cases and extrapulomonary tuberculosis (lymphadenopathia) were a common experience which goes well together with research findings from Tanzania .
To our feeling it was a common clinical lesson that TB was underestimated in PLWHA at the beginning and in the course of the project’s time we started to consider and to treat TB more aggressively, several patients taking antiretroviral drugs and TB drugs at the same time recovered well.
There was no INH prophylaxis done.


Side effects

For the first year there was rarely a problem with side effects, we only had three cases of NVP skin problems which needed a switch to Efavirenz in two cases due to the development towards Steven Johnson Syndrome.
No case of clinical suspicious lactic acidosis occurred in the first year but it is to fear that some patients especially those women put on ARVs (PMTCT plus) because of pregnancy and higher cd4 levels will develop this problem.
Lipodystrophy started to become a problem during the recent months but it is not reported that any patient has switched drugs yet.
The CTC/HAART team started to think about these unavoidable future treatment situations and had already taken efforts to be prepared . There is a vast experience from other countries using the Tanzanian regimens since years and have nowadays changed away from most of the d4T based regimens. This is a normal process and nothing special at all, but teams have to be prepared in time and challenging situations have to be dealt with by experienced staff. These are challenging future situations and the programme had started to prepare for them with suppliers, manufacturers (like Partec in Germany and Action Medeor) and colleagues from abroad (Austria, Canada, Thailand) who were willing to help through their expertise by direct and Internet consultancy.
Likely this year, the issue of Stavudine (d4T) like lipodystrophy and lactic acidosis will be especially pressing and could become life threatening for patients who are not properly monitored. It is well known that for effective long term care a stable mutual relationship between doctor and patient is essential in order to succeed treatment marathon. This relationship has been destroyed by the responsible Elites in the church.



 
Children and Pregnant Women

About 10 children were put on ARV drugs and monitored generally with good success, though for some very young ones the treatment came late and they died.
Fellow children turned out to be very good watchdogs for health care workers and excellent adherence counselors and care givers for other children. They were very thoroughly watching drug intake in their peer group and made sure that the clinic schedules were kept, Children did even the job to be the treatment advocate for an elderly very well .
Syrup and Tablets were used according the recommendation of the National AIDS control program and special computerized sheets were prepared to make sure the right dosing of the drugs.
We think that there is no right to deny any child in the world antiretroviral treatment!
Bulongwa was the first site in Tanzania being able to do direct determination of cd4% for the high quality Antiretroviral Treatment of Children .


Pregnant Women and Prevention of Mother to Child Transmission

Pregnant women were given Nevirapine by the hospital through an AMREF program but we were very keen in doing PMTCT plus and did so with several woman. The life of these women on ARVs is now in danger as nobody is knowledgeable and promoting planned treatment interruption. Especially this group is in an especially high risk of developing lactic acidosis.
We consider Prevention of Mother to Child Transmissions by a single Drug obsolete and it is not done for a child of Elites or Do-Gooders at any place in the world.
Why for the Have Nots? We think the best way of prevention would be good enough for every pregnant HIV Positive women in the world. This is very possible.

Medical Treatment before the lock-out

The medical part is easy compared to the struggle with corrupt Elites.
Our experience matches well with other programs and clinics worldwide (e.g. Haiti, Thailand). HIV/AIDS treatment turned out to be the easy part of the work and growth of patient numbers was only impaired by the immense workload of about 600 patients under care of a small team serving seven days a week. Frequently patients were waiting for care on weekends because of social problems, need of psychological support due to unexpected disease or long walking distance and bad weather.
Paul Farmer and Partners in Health , Doctors without Borders , the DREAM program of St. Egidio with their many publications, or even standard medical textbooks now can be used to study HIV/AIDS care – it is like any other aspect of developed medical care and treatment.
Bulongwa CTC followed generally accepted guidelines based on these experiences whenever possible up to the point when it was violently prevented from going on with improvements to the quantity and quality of care as result of the unwillingness and sabotage of the Elites.
The main drugs that were used were fixed dose combinations of d4T/3TC/NVP and AZT as EFZ and Cotrimoxazole, Fluconazole and Amoxicillin as TB drugs.
Our general impressions and conclusions from this start-up experience are nothing new to the world:
The adherence was very good mainly due to the “trust” in the drugs, extensive teachings and the help of the Treatment Advocates (“msaidizi wa karibu” ). It happened very occasionally that a patient did not turn up for an appointment and rarely was a dose was missed . If so, it was because of severe illness due to opportunistic infections, to the heavy rains that often visit the region or to long walking distances to the clinic. In many such cases, members of the self-help group PIUMA or patient relatives secured the delivery of drugs by walking . Very often the children of a patient’s or the patient’s neighbour’s child turned up in front of the clinic in order to collect drugs. MSF vehicles and the private car of the project coordinator were often used to follow up patients and bring them to the clinic in case they were bedridden.
The originally planned intake of patients was a bit behind schedule as availability of ARVs was delayed for a year. However, intake speeded up tremendously once that bottleneck was overcome and reached 450 registered Patients within 12 Months with 200 under antiretroviral therapy, or 4 times the originally set target for the first year!




The Treatment and Care Situation after the Lock-out


After the lock-out the acceleration of intake of new patients went down and the planned pace for increased enrolment couldn’t be sustained.
Rather the clinic turned into an “ARV distribution site” without proper laboratory monitoring and counselling or side effect monitoring. This probably is also the reason for the again raising death toll. Since the lock out 48 patients - out of about 650 under Care and Treatment and 300 under Antiretroviral Treatment – died by the end of 2006. We consider this number unnecessarily high after more than 24 months of available antiretroviral treatment.
Before the lock out, patient Cd4 counts were recorded on at least a 4 month schedule, even more frequently in cases of obvious clinical failure. Liver function testing was done in case of Nevirapine treatment side effects or any problem considered related to Hepatitis or other liver damage . These services were no longer provided after the lock-out.
The knowledge and experience about second line regimens in case of resistance or long term side effects and expected treatment problems is very poor and none of the present staff has been trained by NACP nor participated in the regular in-house training nor taken part in the daily routine of the CTC before they took over.

The Implementation – Searchers in the field

Officially, the HAART project started 2004, as it was believed that the drugs would be available by that time. However, efforts to find funds, to coordinate with other programs and to clear up hurdles to the importation of the cd4 machine as well as the beginnings of intimations of the upcoming management and financial scandals within the hospital’s leadership - led to delays in the whole project’s timeframe –such that the Care and Treatment Clinic (CTC) could only open its doors in December 2005.
Almost immediately, two key aspects of the project diverged from the planners’ written approach:
Firstly, the training of stakeholders was largely boycotted by BLH and the diocese, as from the beginning no additional allowance was paid for training during working hours . The increasingly intense lack of cooperation from the hospital’s secretive management impaired many of the program’s pillars. With the BLH and SCD it was always unclear exactly who was responsible for decision-making. Community stakeholder training therefore could not be organized in the proposed way.
Nevertheless, the staff working with the CTC - who went on serving with their usual hospital duties as an additional burden - took part enthusiastically in the in-house training that was part of the implementation of the project. They were not expecting additional payments. The patients and their supporters (“msaidizi wa karibu”) tremendously increased treatment literacy during adherence sessions that preceded antiretroviral treatment. These sessions were increasingly done voluntarily by members of the self-help HIV patient group PIUMA. Voluntarism covered gaps that were created by the lack of cooperation by the SCD/ELCT.
Secondly, and more positively, the Involvement of PLWHA was much easier to implement and contributed much more to the patient’s uptake, adherence and well-being than had previously been thought possible; the sick and suffering Have Nots proved that they could really contribute to their own health care. Very often, they put to shame the stigmatizing and greedy health staff and church employees who, as part of the local Elites, were mainly interested in the HAART program as a way to access funds and allowances rather than as a way to solve a health catastrophe.
PLWHA volunteered to be interviewed for a locally produced HIV awareness video and carried out many public speeches and village outreach events whereby they sensitized about 2,000 people in an organized way, distributing condoms and advertising the CTC. As a result, PIUMA was funded as a self-help group by the patients and their supporters with very little financial input. The patients proved that treatment is a political act in the best sense of the word – done properly, a treatment program can empower the Have Nots. PLWHA learned that HIV/AIDS is not a death sentence or a punishment from God.


The team – no success without the Patient

All medical staffs were trained following the regulations of the National AIDS Control Program/MoH and until the lock-out took place, the clinic was running accordingly and effectively.
Staff members were initially paid following the national payroll in order to ensure an unproblematic take over by the government and the church at the end of the start-up period, but as additional duties were taken on by staff and evidence mounted that a lot of money was being stolen out of the hospital funds with a direct impact on the motivation of staff members, top ups began to be paid.
This decision was made in light of the fact that with careful use of the hospital’s income, a small increment in the salaries of all the employees would have be possible without any difficulty. (Unfortunately, the Do-gooders keep the system subsidized even though local Elites are stealing, and the people remain calm because minimal services are still provided).
The staff working and paid by the program but serving the needs of the entire hospital were:
• Two nurses
• One to two Medical Doctors (expatriates)
• Two clinical officers
• One Laboratory technician
• One Orthopedic Technician (combined outreach HIV/AIDS – orthopedic cases)
• One secretary (mainly paid by MSF)
• Two social workers
• One assistant coordinator
• One expatriate volunteer treasurer
• 2 – 7 part time VCT counselors
• One HIV positive volunteer from Austria as peer group educator
• Several volunteers from overseas
Médecins sans Frontières/Spain helped the project by doing the stock keeping of drugs donated to treat opportunistic infections and helped with clinicians during temporary shortages of staff. The cooperation was good and inspiring for the CTC Team.
The most important staff partners, however, turned out to be the sick Have Nots treated at the Clinic . We rapidly came to the conclusion that it will not be possible to overcome the human resource problem in the battle against HIV if the patients and PLWHA groups are not providing their manpower and precious skills and experiences.



Treatment as Preventive Meassure

Due to the de-stigmatising power of antiretroviral treatment (which turns AIDS from a death sentence into a chronic disease) and due to the subsequent advocacy of patients and relatives, VCT rates in the area served by our project increased tremendously by a factor of 10 compared to preceding years at the BLH.
From December 2004 to December 2006 more than 2000 clients were provided with VCT at the site of the Care and Treatment Clinic!
Additionally, through voluntarily PIUMA outreaches, 458 people in 15 villages were tested in late 2006, even after the programme was locked out
Up to 10 counsellors were partly paid by the program and it turned out that this duty was very much prized and thoroughly performed by the hospital’s staff. Extensive discussions about HIV/AIDS and went on within the staff. High status for the VCT and adherence counsellors could be achieved by being helpful to PLWHA.
From the very beginning the programs strived to provide strict confidentiality.

During farming seasons VCT rates went down!

After the violent lock out of the CTC staff and the members of the self-help group PIUMA, the trust of the community in the hospital VCT went down and interest in VCT only returned when village outreaches were organised by PIUMA.

Enlightened and fearless people started asking questions! Probably these questions and the resulting demands for accountability from the local Elites – lead to the lock-out of the program, which was promoted by Elites and accepted by Do-gooders who turned a blind eye and kept a self-serving silence.

The Tanzanian Government’s duty

At October 23rd 2003 President Mkapa announced his government’s intention to treat 40.000 HIV positive Tanzanians by the end of 2004 ; this was repeated as a target for the year 2005 when it was also announced that the goal was to treat 500.000 people by the end of 2008 .
BLH was chosen as one of 20 “quick start” hospitals following the intensive lobbying by the MDA and the procurement of a cd4 counter by partners in the HAART project.
The task of clearing the cd4 counter through Dar es Salaam International Airport and Tanzanian customs was a challenge; it took several weeks to get it cleared by the National Board for Private Laboratories .
The government provided NACP training for two nurses, a pharmacist, two clinical officers and a laboratory technician, while the NACP training for the expatriate MD was paid for by EAWM. On the 17th of November, 2004, an assessment visit was done by the regional NACP team and the clinic was approved and an institutional “strengthening plan” completed.The government provided following antiretroviral drugs, after a delay of about a year, at the end of 2005:
d4t (30/40), EFZ, NVP, 3TC and ZDV
Apart from antiretroviral drugs, the government did not provide any additional financial support to the program.

The Minister of Health and the Prime Ministers Office were informed about the violent lock out of the expatriate staff and the local team as well as the subsequent human rights abuses by Makete/Iringa police. The Prime Ministers Office asked EAWM to contact TACAIDS on the matter which was done on 17th December 2006 .
Tanzanian state authorities, up to today, have not responded to EAWM, though several letters were written and equipment worth about 70.000 Euro is lying idle in Bulongwa and not being used for the benefit of patients.
To date it is not officially known by EAWM if responsible state authorities reacted in any official way to the illegal lockout, the police intimidation, or to the local corruption charges that have been clearly documented, though it was repeatedly reported by the media and publicly said by representatives of government institutions and the Lutheran Church that developing funds and funds to fight HIVAIDS haven been embezzled.


The Implementation – Searchers in the field

Officially, the HAART project started 2004, as it was believed that the drugs would be available by that time. However, efforts to find funds, to coordinate with other programs and to clear up hurdles to the importation of the cd4 machine as well as the beginnings of intimations of the upcoming management and financial scandals within the hospital’s leadership - led to delays in the whole project’s timeframe –such that the Care and Treatment Clinic (CTC) could only open its doors in December 2005.
Almost immediately, two key aspects of the project diverged from the planners’ written approach:

Firstly, the training of stakeholders was largely boycotted by BLH and the diocese, as from the beginning no additional allowance was paid for training during working hours . The increasingly intense lack of cooperation from the hospital’s secretive management impaired many of the program’s pillars. With the BLH and SCD it was always unclear exactly who was responsible for decision-making. Community stakeholder training therefore could not be organized in the proposed way.
Nevertheless, the staff working with the CTC - who went on serving with their usual hospital duties as an additional burden - took part enthusiastically in the in-house training that was part of the implementation of the project. They were not expecting additional payments. The patients and their supporters (“msaidizi wa karibu”) tremendously increased treatment literacy during adherence sessions that preceded antiretroviral treatment. These sessions were increasingly done voluntarily by members of the self-help HIV patient group PIUMA. Voluntarism covered gaps that were created by the lack of cooperation by the SCD/ELCT.

Secondly, and more positively, the Involvement of PLWHA was much easier to implement and contributed much more to the patient’s uptake, adherence and well-being than had previously been thought possible; the sick and suffering Have Nots proved that they could really contribute to their own health care. Very often, they put to shame the stigmatizing and greedy health staff and church employees who, as part of the local Elites, were mainly interested in the HAART program as a way to access funds and allowances rather than as a way to solve a health catastrophe.
PLWHA volunteered to be interviewed for a locally produced HIV awareness video and carried out many public speeches and village outreach events whereby they sensitized about 2,000 people in an organized way, distributing condoms and advertising the CTC. As a result, PIUMA was funded as a self-help group by the patients and their supporters with very little financial input. The patients proved that treatment is a political act in the best sense of the word – done properly, a treatment program can empower the Have Nots. PLWHA learned that HIV/AIDS is not a death sentence or a punishment from God.

Die Medien

XY ist ein guter Freund, seit dem Beginn unseres Behandlungsprojektes, früher war er Lehrer, dann hat er begonnen zu schreiben. Schließlich studiert er Journalismus an der Evangelischen Tumaini Universität in Iringa. In diesem Fall ein positives Beispiel der kirchlichen Arbeit. Bildung hilft.

XY hat uns damals bei dem Film über unser Projekt geholfen, der im ORF und später in 3sat gezeigt wurde und auch bei Missionsgruppen aufsehen erregt hat, wie ich im Internet studieren konnte. Der Film wurde positiv aufgenommen und XY kennt sich besonders gut aus, beim Leid der Waisenkinder.
Er wollte nie, dass man das erzählt: Er hat seine Diplomarbeit über HIV/AIDS, Waisenkinder, Stigma in Medizin, Kirche und Traditioneller Heilkunst geschrieben und festgestellt, dass es beim Stigma immer um Machtmissbrauch und Geld geht.

Er hat für die Arbeit unter anderem ein Mädchen interviewt, das mit den Geschwistern im schweren Regen 3 Tage neben der an AIDS gestorben Mutter ausharren musste. Sie habe ihr noch den Auftrag gegeben, sich um die Kleineren zu kümmern, dann wäre sie gestorben. Wegen dem Regen konnten sie das Haus drei Tage nicht verlassen.
XY kümmert sich seither immer wieder um diese Kinder, deckte ihr Haus, bezahlte das Schulgeld, tat was er konnte, nicht nur für diese Waisenkinder.

Vor kurzem hat er mit seiner Frau die Patenschaft für 2 Kinder übernommen, die keine Eltern haben und die PIUMA aussuchen soll, er möchte sie bis zum Universitätsabschluß begleiten. Er hat übringens eben eine secondary school gegründet für "Ethik und Leadership".

XY war der Beste seines Jahrganges auf der Uni, er wurde von Professoren zum beliebtesten Studenten gewählt, von Mitstudenten zum besten Führer gewählt, er hatte die besten Noten, war Studentenvertreter und beliebt bei allen.

Er hat dann beim "Citizen" gearbeitet, einer der größten Englischen Tansanischen Tageszeitungen, dann wurde er von Jaka Kikwete ins Wahlkampfteam geholt und nach dem Sieg bei der Präsidentenwahl wurde ihm ein hoher Posten angeboten. Er hat abgelehnt und arbeitet weiter als Journalist. Er wolle dem politischen System und dem Land mit seiner Kritik dienen. Der Präsident findet das angeblich sehr gut und XY meint er habe noch nie versucht Einfluss zu nehmen auf seine Redaktion - noch nie! Journalismus ist wichtig für die Demokratie.

Das heißt nicht, dass er noch nicht bedroht worden wäre, er und seine Frau.Vor allem als er begann über die "Unregelmäßigkeiten" im Gesundheitsministerium um die Beschaffung von Labormaschinen zur CD4 Messung zu schreiben und über die Diebstähle von HIV/AIDS und Entwicklungsgeldern durch Staat und Kirche in Makete. Aufgehört hat er trotzdem nicht Titelgeschichten zu schreiben und das hat dazu geführt, dass Statehouse und Gesundheitsminister Untersuchungskommissionen eingerichtet haben, die die Vorwürfe um die Korruption um HIV/AIDS Gelder bestätigt haben.

Es wurde die Staatssekretärin im Gesundheitsministerium abgesetzt und andere Spitzenbeamte mussten gehen. Trotzdem hat der Präsident gestern in einer Pressekonferenz, bei der er Fragen zuließ, gesagt, dass es ihn wundert, dass der Gesundheitsminister nicht weitere Aktionen gesetzt habe, obwohl noch mehr Namen im Report gestanden hätten, er würde sich weitere Aktionen erwarten. Es geht dabei darum, dass Produkte in das Land gebracht wurden, die nicht registriert waren, offensichtlich Untersuchungsberichte zu Ungunsten von Konkurrenzprodukten gefälscht wurden und die cd4 Counter, die wir über ein Jahr verwendet haben, in Makete still gelegt wurden (Fa. Partec/Münster). Seit mehr als einem Jahr gibt es deshalb keine CD4 Werte, weil die Maschine (In vielen Ländern marktbeherrschendes Konkurrenzprodukt um das sich immer wieder Preiserhöhungen zeigen, nach der Marktbeherrschung), die der Minister brachte, nicht funktioniert. Die Missionen und die LMC/ELCT schreiben in ihren Berichten, dass eine "funktionierende cd4 Maschine in Bulongwa" steht - Das ist nicht wahr, das wurde ihnen auch mitgeteilt, die korrupte lutherische Kirche hat sich zum Kollaborateur mit anderen Korrupten erhoben.

Der Präsident sagt, er möchte in jeder Klinik eine funktionierende cd4 Maschine auch in den ländlichen Kliniken, das ist im Moment nur mit den Produkten aus Münster www.partec.com möglich - dem Cyflow - , was auch international bestätigt und hunderte Male publiziert wurde. Wir haben diese Geräte mit großem Erfolg verwendet, eine diebische lokale evangelische Kirche hat das zunichte gemacht, die ELCT hat dazu die Wahrheit verdreht, Vertreter der Missionen aus Übersee haben nicht widersprochen, obwhol sie informiert waren.

Wenn sich die Dinge nicht aus Güte, innerer Moral und basierend auf klarer Ethik ändern, was leider nicht oft der Fall ist - auch im Bereich der Geber - dann sind die Medien nicht hoch genug zu schätzen, in XY habe die Armen einen guten - und mit der Feder erbarmungslosen - Freund und die Demokratie in Tansania auch.

Geber verhalten sich leider oft nicht so klar und transparent wie die meisten Qualitätszeitungen in Tanzania.

Ich bin stolz, dass ich XY kennenlernen durfte, er ist Chefredakteur der größten politischen Wochenzeitung Tansanias und seit er das ist steigen die Auflagen und immer wieder war die Politik nach der Berichterstattung gezwungen zu handeln. Weil er keine Angst hatte auszusprechen!

Ich gratuliere zur Aufdeckung der Skandale im Tansanischen Gesundheitsministerium an der seine Zeitung wesentlich beteiligt ist.

Vor einem Monate titelte seine Zeitung über Makete ungefähr so:

Ihr seid so korrupt, dass ihr schon die Kranken fürchtet.

Es ging dabei um Korruption in Staat und Kirche, um den Diebstahl der Global Fund Gelder und der Gelder der Kirche. Ohne Öffentlichkeit und Medien funktioniert's schlecht, die Gerechtigkeit.

Introduction of the players I: The Have Nots

The Have Nots are the core group and the main players though often not included in the discussion and not participating in conferences or project write up sessions. Here is a huge communications problem!
They are mainly uninformed, downtrodden and most of the times have no sense at all about being part of a major society, a country, and a nation with a legal framework, they survive on local formal and informal agreements and through family ties. They are mostly not aware of constitutional and human rights.
Most of the time the Have Nots do not know that they are the “target group” in many project write ups where they are widely identified as the justification for a demand for money flowing down (although sometimes it flows in the other direction). Most of the time, the money does not serve their interests or reach them in their daily lives. Even if only half of the given funds reach the clinics and hospitals at the end of the line , it does not even mean that it serves the patients .
Typical statements from Have Nots in Makete:
“What to do? That is the money of the church.”
“It is the money of the government (minister, party)”
“It is the money of that (foreign) organization (NGO) or expatriate”
Have Nots suffer under corruption and live lives of great frustration! Very often they work hard, but live worse than a pauper’s life. Too often, their productive power only feeds the Elites. They have little means to cover basic life costs and most of the time no money at all to pay for the education of their children. Many children have been orphaned and are forced to take on the responsibilities of an adult caring for even younger Have Nots.
In the given system Have Nots are trapped in a vicious circle. Disease makes them poorer and poverty is the biggest risk factor for HIV infection.
Paradoxically, their greatest asset is that they have nothing to lose and that they understand very well their situation – nobody needs to explain to them their needs, though this is repeatedly tried by researchers, policy makers and Do-gooders at big conferences, adding to mountains of papers and publications and doing nothing to change the lot of the poor.
As capable human beings, Have Nots can solve their problems quickly and in the most economic manner, but only if they are educated, are asked and informed about policies, scandals and rights. In short, if they are provided a fair and favorable environment, they are their own best experts.
Have Nots are not simply people who are “in need” of “help” They can do things to high standards if they are empowered and given control of their own systems!


Introduction of the players II: The Do-Gooders

The Do-gooders are usually well-educated people, mainly from Europe, North America, and Australia, with an increasing share of the planet’s wealth and the time and resources to do other things as their own basic needs are well covered. Some of them have been working in the “field of poverty and aid” for many years and hold a common view – or are at least pretending to have this view - that every part in the world considered poor and in need can be “developed” through their expertise in education, humanitarianism, planning and programming.
The Do-gooders are separated into two main groups:
The naïve Idealists
Their main aim seems to be to find some meaning in life by helping poor people and “changing the face of the world”. They often overestimate their power to bring about change; some of them invest huge amounts of personal resources and they tend to take over duties that should be done by the legally established systems that are part of a working society and controlled by local governments freely elected by people in the “focus country”. Therefore, they are often unwittingly and indirectly feeding corruption because they deliver services for free while their progress is claimed by people who have been designated by local systems to deliver these services as civil servants. The work of the Do-Gooders gets paid by foreign sources budgets and donations, while the designated government funds for the same services are simply pocketed by corrupt Elites.
The Careerists
Very often these professional Do-Gooders are very well paid and refer to one another as experts. They mainly work in the capital cities of “poor focus countries” and rarely try to put on the shoes of the Have Nots. Sometimes they get physically close to them in air-conditioned 4WD SUVs when they go to talk with their local field officers and sometimes with local Elites in order to get input for their “reports to higher levels”.
In some cases, they are disappointed former naïve idealists. Often they are full of doubt and talk differently about their work while drinking a glass of beer than when they are doing presentations at “high level meetings”, to their bosses, to donors, to conferences, and especially to researchers and program evaluation staff.
The affinity for 4WD vehicles, swimming pools, high society receptions, yacht clubs, and cocktail dinners at international hotels, expensive safari drives and tourist adventures is high among them. It is especially the case with the Do-gooders who are head office staff for NGOs and FBOs, and even with members of solidarity and church groups that are doing “project assessment visits”.
Some Do-Gooders are able to spend an amount of money in just a few weeks that a Have Not in the given country would need about 200 years to earn.


Introduction of the players III: The Elites

The Elites are a group of economically lucky people who are benefiting from the existence of protected niches in globalized, yet underexposed and undemocratic systems that give them access to knowledge, skills, mobility, information and money that allow them a good life. They use diplomatic, political and NGO influence and protection in order to keep these systems running.
They are not used to criticism and they tend to use their local and international networks and power to suppress any discussion about their group!
This class is always trying to protect itself but, often using the umbrella of humanitarianism to camouflage links with similarly protected business interest, working together to keep the pipelines of donor funds open.
Many times the elites have easy access to mostly uncontrolled and badly-monitored development funds that they use to keep the aid business going and serving their own wealth. They fear a free press (for obvious reasons) and tend to influence, intimidate and corrupt it.
The professions that are over-represented in this class are:

• Ministers, politicians and high level civil servants
• Members of Parliaments
• Media professionals
• Clergy from all denominations
• Business people
• Development Experts
• Academics
• Diplomats
• NGO representatives

At local levels:

• Religious leaders
• Degree and diploma holders
• Academics
• Literates
• Health care staff (doctors, pharmacists, district medical officers…)




The Obstacles – Vested Interests of the players

EAWM’s experience convinces us that it is not in the main interest of the Elites and most of the Do-gooders to solve the problem of spread of HIV/AIDS – otherwise the problem would be much closer to being solved and the world would be a different place .
If demand by clients or “customers” exists, usually they get whatever they want delivered to any place in the world, in high quality and in no time. A precondition is that consumers are allowed to choose suppliers and to control their money. Obviously that is one of the fundamental tools that keep the world moving .
(Making a Do-gooder feel good, is not necessarily an asset for the Have Nots in overcoming the problem of a lack of care and treatment or any of their other genuine needs. Rather, it only addicts the Do-gooder to “helping” the poor in order to get more of the feel-good benefit! Sometimes, Have Nots who are stepping out of their oppressed state threaten the Do-gooders by becoming direct competitors in the chase for donor dollars and local esteem.)
The demand of the Have Nots for proper care and treatment obviously exists! Unsurprisingly, Have Nots are the most genuine group and are keen to solve their problems.
The crux is that they cannot pay. They have no insurance and, more importantly, no mechanism for controlling tax money and government budgets which are theirs as citizens. Most of the time, they are not asked and still not included as a capable workforce to address local needs, even though they have skills, knowledge and creativity. They are cut off from information, rights, mobility and communication – which denies them access to the assets of Elites and Do-gooders.
This is in large measure because the Do-gooders and Elites “own” the job of helping the Have Nots. They benefit directly from the conferences about the problems of the poor: they get flights paid, they stay in nice hotels, they work full time on the “challenge”; they feel good about being humanitarians; they develop spiritually and ethically on the backs of the Have Nots; they are living an adventure, getting experience and improving their own market value as development experts; they get awards for helping the poor; they donate some of their own money to feel better… For so many reasons they need the Have Nots. One of the highest profile and most powerful among them even called the dreadful burden of AIDS “quite a gift” .
Have Nots provide the justification, the ongoing need for aid that keeps the system running and subsequently feeds the interests of the Elites. The Have Nots create thousands and thousands of jobs for the Elites!
When Have Nots are taught and allowed to use self-determined means, they no longer need the Do-gooders or the parasitic Elites any longer. Here is an ironic and destructive conflict of interest!

The Situation in 2003: “Everybody knows somebody”

Late 2003, a member of the Makete Development Association (MDA) – a Dar es Salaam based NGO built by people originating from Makete – reports:
“Makete HIV/AIDS problem has been widely publicised during the HIV/AIDS week in our local papers. It is alleged that 80 to 90 % of inpatients in the Hospitals are victims of the disease...
...Most young people interviewed claim that condoms are not readily available and that economic hardships have a part to play in making them fail to buy condoms. They say one condom is used more than once (sic)...
...The Education sector has been severely affected. In the last three years 150 staff of the District Council have died most out of HIV/AIDS! They say the statistics available are a gross underestimation of the magnitude of the problem because many people in the village who cannot afford medical bills lie dying in their homes! In the month of September 2003 alone 21 teachers have died.”[i]
The Iringa Regional Government Authorities in December 2002 said that Makete District had 5,604 HIV/AIDS infected persons and it was leading in the Iringa region for having the highest number of reported cases of infection[ii]. The prevalence of HIV in the adult (15 – 49 years) population of Tanzania was calculated at 7,8%; the number of infected people including children was calculated at 1,5 million.[iii] Reliable epidemiological data for Makete District were, to a large extent, not available. This situation has not changed much, but the best estimates of prevalence are probably between 15% - 20% in Makete District[iv]
There were HIV/AIDS Control Programmes at Bulongwa Hospital since 1988 that were started by a missionary doctor who now holds a post as one of the directors of the Global Fund to Fight AIDS, Tuberculosis and Malaria. In 2002 a programme supported by CARE International dealing with HIV/AIDS, Reproductive Health and Save Motherhood was reportedly undertaken at BLH.
The state of awareness of AIDS in Makete District[v] is high with one study indicating that 94,1% of interviewees have heard something about HIV/AIDS. Sexual intercourse (90,5%), blood transfusion (12,4%), equipment such as needles, scissors and razor that are not properly cleaned or sterilised (23%) were known to be pathways of transmission. Possible means of prevention from HIV/AIDS infection were considered to be abstinence (54,6%), faithfulness (32,7%) and condom use (31,6%). Most of the people were not aware of their own HIV status, as VCT (voluntary counselling and testing) was not available or used to a major extent.
Not much was known about the possibility of life-saving Antiretroviral Treatment! It was not common to talk about HIV/AIDS with patients or to write this diagnosis on patients’ files.


The “Write Up“– Planners on the run

The planners for the HAART project were a small group of representatives and supporters of the local community in the Bulongwa area of Makete District, the staff of Bulongwa Lutheran Hospital and EAWM[vi]. Foreign expatriate staff was officially invited by the Bishop of ELCT/SCD[vii] and EAWM was asked to look for financial support; local support with a conducive environment and proper accounting was promised.[viii]

From the very beginning, the main pillar of intervention to overcome the plague was thought to be the participation and leadership of PLWHA and to follow local rules and agreements.

EAWM planned to donate and hand over an integrated, self-supporting and well-working programme to Bulongwa Lutheran Hospital after an initial phase of three years.

Consequently, all the actions were planned to be carried out according to the rules and procedures of the NACP (National AIDS Control Programme) in order to facilitate future government support. Financial capacities of the country and the partner were thought to have been taken into account[ix], especially when it came to the calculation of salaries[x].

International scientific literature and best practices as well as recommendations of local people were considered[xi].
Most of the 2003 proposed tools are common international knowledge nowadays though still waiting for wider implementation. At the International AIDS Conference 2006 in Toronto/Canada titled “Time to deliver” most of the scientific discussions about interventions were declared closed and implementation was demanded.
Therefore, we do not think that it is necessary to repeat and discuss all the means to fight AIDS over and over again, rather the question for today is:
Why are so many still dying though we know very well what works technically and scientifically?
We think our experiences may deliver a part of the answer.

The proposals of the planners in 2003 for Makete in short:

Involvement of PLWHA from Tanzania and overseas to overcome stigma and use them as treatment advocates and health workers for their fellow PLWHA which should lead to creation of self - helped groups advocating for human rights
Antiretroviral Treatment as a means to promote awareness and to reduce the existing discrimination (Medical Setting was planned to followed guidelines of NACP/MoH of Tanzania and the 2003 WHO guidelines and were extensively described in the proposal)
Incorporation of Grassroots Leaders including every willing governmental or private person or organisation including traditional care providers (birth attendants and healers), community health personnel, teachers, religious leaders, youth in schools, etc.
Coordination with Complementary Programs and other NGOs like DanChurch and CARE International
Gender Issues concerning basic rights and self-confidence of women
Conducive Economic Setting and Employment Creation in order to minimise mobility and migration of the people
Promotion and Distribution of Condoms for at least people tested positive
Promotion of Male Circumcision
Awareness and Cultural and Social Training Promotion and encouragement of peer groups to be engaged through Anti-HIV/AIDS Clubs, School Programs, and Church Congregations and workplace activities, implement public cinemas, debates, and cultural entertainments
Fighting traditions of inheriting wives in families and the myth that their loved ones die because of witchcraft
Cooperation with the local District Council to help and to look into ways of imposing by-laws that may contribute to minimising the spread of the epidemic
Prevent over-indulgence in alcohol in order to prevent engagement in unprotected sex
Improvement of the nutritive situation of the population and especially of PLWHA


[i] Sanga R., E-mail to EAWM from17/12/2003, the author is a board member of Makete Development Association, Dar es Salaam
[ii] Fulgens F.A. Malangalila, “Makete District HIV/AIDS escalation needs recognition now”, The African,13/5/2003
[iii] UNAIDS 2002
[iv] Not published data from EAWM/MSF from the MCHC clinic and PMTCT programs the prevalence was about 18% in pregnant woman visiting Bulongwa CTC in 2005, for Makete District Hospital it was reported up to 29% in 2006
[v] Sigalla, 2003, „Investing in Healthcare for Sustainable Development: Its Viability for Rural Socio-Economic Change: The case of Makete District in Tanzania”, master theses, Department for Social Studies, Kepler University – Linz/Austria
[vi] The proposal was called “A Comprehensive Approach to Treat HIV/AIDS due to the Invention of Modified DOT-HAART (Directly Observed Therapy with Highly Active Antiretroviral Therapy)A Two - Phase Project Proposal, Phase 1: 2004 – 2005 (pilot),Phase 2: 2006 – 2008 (scaling up)” and presented to ELCT, CSSC, NACP and the Austrian Development Association early 2004. The write up is available at EAWM’s office under eawm@magnet.at.
[vii] Letter of the bishop to EAWM dated 28/07/2003, inviting EAWM to carry out the program and especially welcoming the EAWM staff promising every possible support by SCD
[viii] Memorandum of Understanding between SCD/BLH and EAWM from 2/04/2004, signed by the bishop, hospital’s doctor in charge and designated EAWM project leading medical expatriate doctor
[ix] Today EAWM thinks that in the planning phase, the existing financial capacities especially in the Lutheran church were underestimated, while the will to show accountability was overestimated
[x] Salaries were planned following the government scales but were later on increased because of extra work loads and because program staffs did not have access to other sources of income like allowances for being out of work for training or for private business during work hours. Hospital Elites benefitted by unlawful access to funds and their “income” was much higher than that of program’s staffs.
[xi] Late 2003 several meetings with community stake holders, church representatives, hospital staffs and local experts were done and the knowledge of local graduates and researchers was used. An extensive e-mail exchange with Makete Development foundation representatives and EAWM is available.

Zum Kommentar vom 14.Mai

Anonymous hat gesagt...
Sehr geehrter Herr Dr. Brandl,Ihr neuer Kommentar stimmt sehr, sehr nachdenklich...An die "kranke Grossmutter" glaubt ja in Afrika selbst niemand mehr ernsthaft, aber es ist schon bezeichnend, dass die kirchlichen Hilfswerke nicht nur die Augen und Ohren und Münder verschliessen sondern - wenn man ihren Ausführungen Glauben schenken darf - auch an einer Klarstellung der Misswirtschaft nicht mitwirken. Ich habe heute zufällig die Website des DZI besucht und festgestellt, dass keine der von Ihnen genannten Werkedort registriert ist. Das gibt Anlass zur Sorge. Ich hoffe sehr, das Vernunft einkehrt und das offene Gespräch - auch mit den Betroffenen vor Ort - gesucht wird. Bitte informieren Sie weiter und bleiben Sie am Ball !Mit besten GrüßenL.E.
10:28 PM

Lieber L.E.

Sie können beim EAWM und bei mir, bei Menschen in Tansania, aber auch bei den Werken Berichte haben, die die "jahrelangen finanziellen Unregelmäßigkeiten" belegen. Ich kann die Kontakte herstellen.

Mich stimmt das auch sehr nachdenklich. Auch dass die Vertreter jener Missionen, die nicht beim DZI registriert sind, dann aber offensichtlich mit Stimme in den Gremien in Tanzania sitzen und in deren Publikationen dann wieder Projekte beschlossen/vorgeschlagen/abgedruckt werden in der SCD, wo die finanzielle Lage um die kriminellen Vorgänge noch nicht abgeschlossen sind. Ich verstehe das alles nicht.

Ich habe in den letzten Monaten erlebt, dass ich von Afrikasekretären beschuldigt wurde offen zu lügen, ohne die Lüge zu benennen, dass mir in einem Brief an den Tansanischen Präsidenten unterstellt wird, dass ich quasi Konflikte zwischen Moslems und Christen säen würde (einer kompletten Lüge zugrunde liegend) und so weiter und so fort... die Zustände in der Diözese sind seit Jahren bekannt und von ELCT und auch von Missionen wird zuerst Monate- und Jahrelang nicht auf Anfragen/Berichte aus Tansania reagiert und zwar erst dann, wenn Briefe wütend werden. Dann wird rasch meine Sprache zum Problem erklärt und gesagt, dass ich wohl glaube im Besitz des Rechts zu sein - aber diskutieren könne man nicht und überhaupt, was solle man denn machen?

Leistungsgerechte Bezahlung der Missionsekretäre, pro eingeschultem Kind, pro-.....? Dann würde ich mir auch die Vorwürfe, Verdrehungen und Lügen nicht anhören müssen, weil dann hätten die wirklich anderes zu tun.

CAVE! nicht der Tod der Menschen, die Menschenrechtsverletzungen, die Korruption, der Missbrauch der Spendengelder, das jahrelange Fehlen einer adäquaten Reaktion, die sterbenden HIV/AIDS Kranken, die Skandale um die Labormaschinen und HIV Tests... alles in den Titelseiten der Tansanischen Presse... (wahrscheinlich alles ein Komplott vom "Kolonialisten" Dr. Brandl?) nicht, die gestohlenen Autos, die Projekte die nicht exestieren, nicht, dass nicht auf die Anfragen von Tansanieren reagiert wurde, nein... meine Sprache, mein Ausspruch "soft killer"... mit dem ich jene bedacht habe, die bei Menschenrechtsvergehen durch die Kirche zugeshen haben, aber wahrscheinlich habe ich das alles auch noch inszeniert am Ende, mich selbst aus dem Krankenhaus geworfen, alle Publikationen über die Labormaschinen gefälscht, die Auditoren bestochen und den Generalsekretär der Diözese gekauft, wahrscheinlich alles nur ein "Gottloser".

(Es hat mich in dem Zusammenhang sehr erschüttert von Afrikanern zu hören, dass wohl Gott nicht exsitieren würde, wenn er solches zulasse - das gibt den Pastoren und den Missionsekretären sicher nicht zu denken?)

Ich bin der Meinung Korruption und diese Art der "Entwicklungshilfe"töten und verhindert Entwicklung, der Profit liegt bei den lokalen Eliten in Kirche und Staat und NGOs und nicht bei den Armen, das schreibt auch der neue Nobelpreisträger Yunus. Das ist aber den Missionen keine Diskussion wert, man "habe anderes zu tun".

Besser es gäbe sie nicht.

Bei PIUMA gibt es einige Entwicklungen, die Hoffnung machen und denen ich mich in Zukunft lieber auf diesem Blog widmen würde. Es gab so viele die mithelfen und bangen und die wohl eher and den HIV/AIDS Kranken und der Entwicklung der Armen interessiert sind, als an der Verwicklung von Missionswerken in Spendenskandale und an ihrer und der ELCT sonderbarer Reaktion, die Opfer zum Problem zu reden. Das, anstatt sich mit offener Aufklärung und Ausräumung der Probleme in gebotener Zeit, zu beschäftigen.

Ich werde daher diesen Blog splitten und einen eigenen neuen Blog anlegen, wo ich die Briefe und Mails, die Dokumente veröffentlichen werde (ohne Namen) die wohl ein Sittenbild der Missionsgeschichte geben werden. Für die die mich auffordern weiterzuschreiben.

Auf diesem Blog werde ich micht mit dem Leben beschäftigen. Ich bin Arzt und wollte helfen, konsequent helfen und ehrlich - wie ich hierhergekommen bin in solche Diskussionen und solch sonderbare Menschenverachtung, das frage ich mich immer mehr, ich habe dazu kaum mehr Lust und Kraft.

Dear Dr. Brandl To EAWM organisations opinion the agreements were not fullfilled from ELCT side. Can you specify, who was the counterpart of your organization in theese contracts ?Ashante for clarification
5:43 PM

Dear Sir, see the memeorandum of understanding, it was those times signed by myslef on behalf of EAWM and by the Bishop of SCD/ELCT and the Dr in Charge/BLH/SCD/ELCT.

The whole report gives a lot of insights even about your questions and if you read the notes, it is available under eawm@magnet.at.

I put in bold what in EAWM's oppinion was not fullfilled by ELCT side (mainly SCD but with increasing share from the ELCT headquarter side). For further information and copies of the many letters of EAWM board and representatives to SCD/ELCT representatives where most if them went unanswered (remarks in brackets):

Memorandum of Understanding on the Management and Support of the Program Entitled as:

“A Comprehensive Approach to Treat HIV/AIDS due to the Invention of Modified DOT-HAART (Directly Observed Therapy with Highly Active Antiretroviral Therapy)”

Initial Phase: 2 Years at Bulongwa Lutheran Hospital, the contract of the expatriate may be renewed yearly in agreement with EAWM of Austria and South Central Diocese and Bulongwa Lutheran Hospital.

Program partners and responsible signatories are as follows:

Rt. Rev. Bishop Shadrack Manyiewa on behalf of South Central Diocese, P.O. Box 22, Makete, Tanzania

Untw’alinamaka Kusiluka/Administrator and Dr. Godfrey Mpumilwa/Doctor in Charge on behalf of Bulongwa Lutheran Hospital, P.O. Box 42 Bulongwa/Makete, Tanzania

Dr. Rainer Brandl/Program Co-ordinator on behalf of EAWM (Evangelical Association for World Mission) Vienna/Austria

Presumptions:

The fundament for the proposed program was laid in early 2003 following the raising awareness of the escalating HIV/AIDS situation in Makete District, at the same time there were discussions coming up within international NGOs and the international community regarding the outstanding promotion of Antiretroviral Treatment for approximately 95% of the world’s HIV/AIDS victims. The proposal was worked out and promoted since July 2003 in close co-operation with BLH and Makete Development Association/Dar es Salaam.
The Doctor in Charge and the Program Co-ordinator have taken part in the EACS Conference 2003 at Poland.

(remark: I paid for the travel costs of the Tanzanian colleague and his participation at the conference out of my own pocket - no EAWM or Tanzanian funds were used)

These MDs have partly been on training for up to 3 months at a HIV/AIDS department and a department for Obstetrics and Gynaecology in Austria. This training has been organised and partly financed by EAWM. The major part of the costs was covered by private donations of the proposed program co-ordinator who prepared himself during the course of the last year in order to gain skills for the program’s need.
Neither the time of preparation nor the planned program would be possible without the accepted low salaries/allowances and the voluntaries within the hospitals staff and without the donations by the program co-ordinator and the donations of his friends and parents.
It is to emphasise that a number of people having taken part voluntarily in the preparation and without their support this work would not have been possible. We are especially grateful to Mr. Rayben Sanga/CPA and member of MDA (Makete Development Association), Dr. Huruma Sigalla/Sociologist/Austria, Dr. Godfrey Mpumilwa/BLH, Mr. Untw’alinamaka/BLH, Erika and Walter Brandl/Austria, Dr. Arno Lechner/Austria and Mag. Gottfried Mernyi/EAWM.

The preparation and calculation has been carefully done in a manner of saving funds and targeting the afflicted group of PLWAH (people living with HIV/AIDS). The decision of the program lead MD to stop his medical education for upgrading to a specialist for surgery was facilitated by the fact that it is most likely one of the biggest challenge for a Doctor in these days: To take part in saving people who easily could be saved! The huge mass of PLWHA in this world are just neglected and denied their human rights for treatment and care. It is the main objective of the program to care for these people and to prevent the further spread of the disease. We are on the battlefield against the murdering terror of infectious diseases - especially HIV/AIDS. It has to be announced as the real war against terror in these days and not much money is spent compared to the amount poured to the killing industries.

The program partners and signatories are keen to work together with people in the same commitment only. All the participants should either be committed to the program’s objectives or should be asked not to interfere with the various proposed efforts.

The management structure will aim towards a non hierarchic, discussion based, equality promoting and quality facilitating style, flexible and fast adapting to the need of the society suffering under HIV/AIDS.

1) The program will deal with the following issues which are comprehensively described in the detailed proposal:


Involve People Living with HIV/AIDS
Introduction of Modified DOT – HAART (Treatment with Antiretroviral Drugs)
Voluntary Counselling and Testing
Incorporation of Grass Root Leaders
Coordination with other complementary Programs and NGOs
Gender Issues
Conducive Economic Setting and Employment Creation
Promotion and Distribution of Condoms
Circumcision
Awareness Cultural and Social training
Administrative and Legal Regime
Alcohol
Improvement of the nutritive Situation of the population and esp. the PLHA
Operational Research

2) Responsibilities of the Program Co-ordinator are as follows:

Overall co-ordination together with the likely future co-ordinator.
Implementation of EATG (Emergency AIDS Treatment Group) by creating a conducive environment
Teaching on medical issues
Medical supervision
Co-ordination of the training programs
Co-ordination of eventually undertaken research
Reporting to the donors in co-work with hospital’s administration
Co-ordination of visits by PLAH from overseas
Write ups of by the EATG and community developed strategies
Control of the program’s budget

3) The partners confirm their willingness and strong support to work together in avoiding the possible weaknesses and obstacles of the program which may be:

Lack of Drugs
Quality of Drugs
Shortage of Medical Staff
Financial Constraints
Contradiction in Spiritual Beliefs
Lack of coordination to other programs with related targets carried out within the area of South Central Diocese.

4) Financing, Financial Management, Reporting, Monitoring and Auditing

Financing

EAWM/Austria has managed to solicit funds for the start up of the program’s initial two years phase. These funds will be supplied by the Austrian Government/Austrian Development Association and the Lutheran Church of Austria and private donations. These funds hardly cover the budget for the initial phase of the program (presuming that the Hospital is accepted for the government’s “Quick Start” Program launched by the Mkapa/Clinton Initiative) and are strictly to be used according to the budget calculation. The chairman and the secretary of EAWM are personally responsible to the Austrian Government and the Board of the Lutheran Church of Austria. This is acknowledged and carefully considered by the program partners.

The costs for salaries and offices expenses of EAWM in Austria are fully covered by other sources, the program’s budget will not be touched for this reasons.

The program partners will strive to open different channels to sustain the program’s budget. This will mainly focus on following duties:

For the Diocese and the Hospital:

To open the government sources for further staff grants according to the hospitals human resource developments plan respectively the program’s staff plan.
(remark: instead it is documented that the hospital and diocese did not pay taxes for a time or with a long delay - nothing was done to sustain the hopsital in favor of the patients)
To strictly maintain and report the PPF’s budget and development in order to increase accountability which this will hopefully lead to a sustainable support by the donors. PPF – which role is described extensively in the program’s proposal and the statutes - is funded from different private sources and small NGOs both from local (MDA) and overseas (former volunteers and staff, parishes and EAWM).

(remark: PPF is a so called poor patient's fund - reports are missing - at the time the program was working we took over this duty, to be fair: one treasurer tried to keep the books, but in general the SCD/ELCT/BLH is far from managing the fund - correpsondence at all to the donors, we are not sure if the money spent by Wakinga from Dar es Salaam or overseas was used for the poor sick and needy)

Actively seeking for dedicated partners within the country who will be supportive to the program’s objectives in a fund saving self supporting and income generating manner.
Actively striving for the support of the responsible persons and mechanisms within the country and the international community.

For EAWM and other possible partners:

To strive to open channels to further support the program’s sustainability. This work will be facilitated and eased by a clear and transparent documentation of the ongoing implementation. EAWM will use all the possible contacts and channels in Europe.

Program’s Budget Management

The program will have a separate budget, bank account (Signatories will be Programs Co-ordinator, Dr. in Charge, Administrator and Treasurer) fund control and reporting systems. The program co-ordinator shall be primarily answerable for the proper management and control of program funds.

Accounts and accounting records

Accounts will be held and updated by the program’s secretary and computer operator in close cooperation with the program co-ordinator, the hospital’s treasurer and BLH administration. (remark: most of the time there was no hospitals administration and far from being ready to coordinate, the program was rather atacked for not getting the funds under controll of Diocese/Bishop/Hospital's Staff) It will be presented to the diocese authorities in a yearly prepared package. For controlling purposes the diocese authorities and the external auditor and EAWM/Austria can evaluate at any time.

External and Internal Monitoring and Auditing

PIMA Associates led by a PCA and member of MDA is willing to do the overall auditing, which will also be done by the internal ELCT – South Central Diocese and ELCT - Health Department auditing process.

(remark: PIMA Associates for obvious and understandable reasosn refused to take this job as it was seen as a conflict of interest as its stakeholders were very much engaged in promoting and preparing the programme for the Diocese. The Diocese and ELCT did not make any attempt at all to provide technical assistance or any auditing process)

5) Program Implementation Evaluation

Evaluation of the program implementation has to be done every quarter in written reports, distributed to the partners and financiers.
The terms of references are described in the program’s proposal.
With the possibility of technical assistance by program partners we shall invite external medical personnel or NGOs (most likely Medicines sans Frontiers) with experience and skills in managing similar programs or activities to visit our Hospital once a year (at least in the pilot phase) to do medical auditing.
The audit shall focus on assessment of whether the program is on course; determine attainment of the program objectives and advice for possible adjustments.

6) Salary, Accommodation, Transport and Support of Program’s Co-ordinator

Salary of the Expatriate Program’s Co-ordinator will be paid by the program through the accounts of EAWM/Austria including income taxes, health insurance and pension fund according to the Austrian laws. Beside a flight ticket one times a year there are no further allowances given. Holidays and free time should follow Austrian laws and local agreements (5 weeks/year). The expected once a year trip to Austria will also serve for reporting and fundraising purposes.

Accommodation within the hospitals area shall be provided free to the expatriate and his relatives. In case other visitors will be accommodated at the hospital’s area not participating in the hospital’s work or the program they will be charged for a moderate accommodation fee by the hospital.

In case the Co-ordinator will build a house out of his own pocket the hospital and the diocese will make sure that there is no lost for the expatriate either by compensating for the construction costs or by leaving the house for his future use (e.g. for visits or tourist business, whereby the income will be shared with the hospital for maintenance and organisational reasons) for 20 years.

In case a house will be built at private land the hospital/diocese is assuring full support in technical and governmental issues for the program’s course of time.

Food and housing staff will be paid by the expatriate himself.

Transport for private reasons will be fully paid and organised by the expatriate himself. In case he manages to buy a car – which is not budgeted in the program – out of his own and/or private properties, the hospital/diocese will assist using their purchase channels in order to make use of tax exemptions.

(remark: I bought two cars privately and out of my pocket, used it mainly for the projects purpose, while hospital cars were used for business, nobody helped for taxexemption, I am a very good foreing taxpayer in Tanzania, while I used my private property mainly for the poor and for social and development work, as a good as I could understand, while the tax expemted church cars are reportedly used for the private business of church representavives, one hospital owned car surely worth about 30.000 US$ was reportedly sold for about 4.000 to one of the hospital's staff without any documents.

(This information is from the audit reports paid by NMZ/Mission One World (bavaria)/KPS and EAWM - beside EAWM all the other missions did up to now only react "internal" (that is what they say) and want to solve the problem within ELCT. EAWM has left the cooperation with ELCT this months officially - as nothing is moving which helps the people on the ground, this was declared even to the Lutheran World Federation, obviously also not able to work in favor of the betrayed poor of Makete)

Nowadays, I see my behavoiur as a typical countrproductive attitude of a do-gooder, who keeps a bad system running by funding it from outside, while ressources are stolen or mismanged)

Whenever the car is used for program’s purposes, km according to the common rates will be paid to the cars owner out of the program’s budget.
As the expatriate will pay privately for this car he is free to make use of it according to his own plans including rental, cost sharing and selling decisions. The expatriate will try to make sure that the car serves a community based development program after he left the country.

The hospital and the diocese will make sure to assist the expatriate in any official/governmental issue which is facilitating and necessary to smooth his stay, (e.g. obtaining a working permit, securing his right in front of officials/government).

(remark: I may just laugh here, as at no time the diocese was able, since the very beginning when we were in good understnandign to assist with permits, everything was done by myself and EAWM and supporters outside the church aho worked voluntarily for the sick and the poor and could have been seen as supporters of the church - unluckily the ELCT missed this chance)

7) Program’s visitors from overseas

Visitors who are substantially supporting the hospital either by work or by donations are whole heartily welcome and should stay for the same conditions as the expatriate, they will just share for transport and food. Decisions upon this status will be made following the information submitted by either the co-ordinator or EAWM secretary.
Other visitors have to find their way to Bulongwa by themselves in case they are invited by the hospital’s management. The accommodation will be provided by the hospital/diocese for a faire rate which also generates some income to the hospital.

Makete, 04/06/2007


Rt. Rev. Bishop Shadrack Manyiewa Dr. Godfrey Mpumilwa



Untw’alinamaka Kusiluka Dr. Rainer Brandl