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.