MIZZOU NEWS

Fighting AIDS in Africa

Shattering Africa’s Deadly Taboo: Unconventional outreach brings AIDS programs to rural villagers

Note: Story by Neal Fandek and photos by George Poehlman were published originally in the winter 2002 issue of Missouri Medical Review, an alumni magazine published three times a year by the MU School of Medicine.

In a remote sub-Saharan country, hundreds of villagers traveled to an unprecedented meeting. Their leaders were going to shatter centuries-old customs related to sexual behaviors and disease by discussing the cause of constant funerals in the villages. When the village leaders and traditional healers had gathered in a circle, they listened to George Poehlman, MD ’73, describe how to fight AIDS in Africa.

Poehlman told the villagers that they could no longer rely on him or other foreigners at the nearby mission hospital to save them from AIDS. Their only hope was to change age-old beliefs that allowed AIDS to spread unabated. For education and prevention programs to have any impact, AIDS could not remain a taboo subject.

The villagers’ chief responded with a powerful admission. “Too many of our people are dying,” the chief announced in a pledge of support for Poehlman. “We will do everything we can to help you.”

The breakthrough meeting launched the first community-based education, prevention and treatment program for AIDS in Malawi. The program was created in 2000 by Poehlman, his wife and other volunteers at a mission hospital in the northern region of Embangweni. Funded by UNICEF, the program is designed to prevent the spread of HIV — especially mother-to-child transmission — through a unique outreach initiative called Tikoleranko, which means: “Let us unite.”

Instead of waiting for villagers to come to hospitals, Tikoleranko reaches out to them by establishing a presence in their communities. It enlists the cooperation of influential village leaders and traditional healers, and it communicates through traditional songs and dances. The ultimate goal of Tikoleranko is to reduce the villagers’ reliance on
foreigners by teaching them to run sustainable education, prevention and treatment programs.

After 16 months in Malawi’s impoverished and isolated villages, Poehlman has a theory about why more physicians have not taken a similar approach to fighting AIDS
in Africa. “Physicians — like most foreigners in Africa — want to work out of the cities, yet 86 percent of Malawians live in the bush,” he says. “I realized that any meaningful work on AIDS would have to be done in the communities where people actually live. That working in the bush is the only way to overcome our biggest challenge — changing villagers’ attitudes toward AIDS.”

Sub-Saharan nightmare

Before leaving his home in North Carolina in 1999, Poehlman promised himself that he would not get entangled in the nightmare of AIDS in Africa. Seventy percent of the world’s 36 million HIV and AIDS cases are in Africa, and the vast majority of Africans have no access to drugs for AIDS or associated diseases such as tuberculosis.

Sub-Saharan countries are the worst affected, and tiny Malawi has become a symbol of their despair. About 9 percent of Malawi’s 11 million people are infected with HIV. And with an average annual cash income of about $180, Malawians can’t afford condoms to keep from spreading the virus much less the cost of anti-HIV drugs.

An 8-year-old boy rests at the mission hospital in Malawi. Many villagers would only travel to the hospital after their traditional healers had failed. Too often, hospital physicians could do little more than comfort the dying. The boy died just days after MU resident Tamara Helfer took this photograph.

Consequently, Malawi’s AIDS mortality estimates are appalling. According to Poehlman’s figures, half of 15-year-old Malawian males will not live to see 30. “If we announced that half of the 15-year-old boys in Sweden would not live to 30, there would be an international outcry,” he says. “It’s because it’s Africa, because they’re black and because they’re impoverished. It’s OK for Africa to suffer but not us.”

Poehlman learned about mission opportunities in Malawi from a former resident he had supervised at East Carolina University in Greenville, N.C. Before directing the family medicine residency program at the university, Poehlman had a private practice for 16 years and served two years on the family medicine faculty at MU. In 1994, he received a degree in public health from George Washington University in Washington, D.C., where he specialized in health promotion and disease prevention.

Malawi is billed as the warm heart of Africa because of its friendly people and stunning natural beauty, but Poehlman knew the country had many problems when he convinced his church to sponsor his work at the mission hospital. Despite three weeks of orientation for the trip, Poehlman was shocked when he arrived in Malawi’s capital in October 1999. “It was much more destitute than I had envisioned,” he says.

Riding on bumpy dirt roads to the hospital, Poehlman resigned himself to living in little more than a mud-thatched hut. What he got was Spartan by American standards, luxurious by Malawian standards. His new home had cement floors, brick walls and plumbing. Solar panels pumped out sporadic electricity.

The nearby hospital has 134 beds and serves about 100,000 people from as far away as the neighboring country of Zambia. Besides delivering more than 1,200 babies each year, the hospital is the primary provider of treatment for malaria and other endemic diseases.

Shortly after his arrival, Poehlman helped establish a tuberculosis education, prevention and treatment program. While gathering important data about the disease in Malawi, he discovered that more than 80 percent of his patients with tuberculosis also were infected with HIV. “I went to Malawi swearing that I would not get wrapped up in AIDS, but there was just no way to avoid it,” he says. “It is destroying the country.”

But no one around was trying to end the devastation. For workers at the hospital, which had precious few HIV test kits and no anti-retroviral drugs, there seemed little point in even discussing AIDS. “The rule when I arrived at the hospital was ‘We don’t talk about it,’ ” Poehlman says. “And in the communities, people with AIDS were still viewed as lepers. The truth about AIDS was unspoken, yet the disease could be found in every household.”

Village outreach

Poehlman’s plan to fight AIDS was based on a comprehensive program he had helped create to fight tuberculosis. The program provided training to the staff at the hospital and its three clinics. It established 16 mobile clinics to take education and treatment efforts directly to villages. It trained village leaders and traditional healers to serve as spokespeople for prevention and treatment.

The tuberculosis program’s unconventional approach to outreach was a success. By taking its message to the villages, the program more than doubled the number of tuberculosis patient referrals to the hospital and clinics.

But Poehlman and his colleagues would need to expand their unconventional approach to spread information about AIDS. Before 1994, public discussion of AIDS was forbidden by a dictator who ruled for 30 years. According to the government, AIDS didn’t exist.

The dictator even banned the language of northern Malawi, and nearly all northern villagers had no access to newspapers, radio or television. “Among the villagers, drama is the means of mass communication,” Poehlman says. So he and his colleagues enlisted local singers, dancers and storytellers to give dramatic presentations about AIDS.

The effort would break down the code of silence about AIDS and change other traditions associated with the disease. For example, when the villagers gathered to launch Tikoleranko, the chief issued a warning to men who followed the custom of marrying their brother’s widow. “Before you enter your brother’s house, ask yourself what you are taking to bed,” the chief said. “It could be your death, too.”

Other cultural barriers to AIDS prevention include polygamy, casual attitudes toward prostitution and allowing husbands to have extramarital relations while wives breast-feed. All children are breast-fed by mothers or wet nurses because there is not enough formula, clean water or bottles to do otherwise, Poehlman says.

In sub-Saharan countries, HIV infection among children is almost exclusively attributable to transmission from mothers during late pregnancy, delivery and breast-feeding. Poehlman estimates that up to 38,000 infants contract HIV from their mothers each year in Malawi.

In 2000, UNICEF awarded five years of funding for Tikoleranko and the mission hospital to address mother-to-child transmission through outreach education, testing and anti-retroviral therapy. Transmission rates already have been reduced 90 percent by administering nevirapine at the time of delivery, Poehlman says.

Poehlman and his cohorts at the hospital were the first to receive UNICEF funding to distribute the oral drug to mothers and infants in Malawi. At that time, no African country supplied the $4 regimen of nevirapine.

Winning UNICEF support was one of many philanthropic victories for Poehlman’s team. They also convinced UNAID to loan them an HIV-positive counselor who chose to stay at the mission hospital. They received supplies from Malawi’s minister of health, and their church provided money for workers and a new AIDS resource center. They convinced a chief’s daughter-in-law to serve as director of the center, giving its programs instant clout among villagers.

“In many ways, we were typical ugly Americans — pushy, aggressive, obnoxious. But it worked,” Poehlman says. “We asked for and got what we wanted again and again.”

Mission for physicians

Western countries often are criticized for not doing more to fight AIDS in Africa, which lacks both the resources and leadership to fight the disease. In addition to the critical need for costly medications, there is little money to help organizations like Tikoleranko and the mission hospital address AIDS-related problems such as hospice and orphan care.

Orphan care is the “ears of the hippo,” the first glimpse of the devastation in store for Malawi and other sub-Saharan countries, Poehlman says. Adults in their most productive years are being wiped out, leaving grandmothers and children to perform the backbreaking work of manual farming. “Mass starvation is just a step away,” he says.

How can doctors make a difference? They can give money or time to local church and service groups with AIDS missions and support international organizations like Doctors Without Borders. They also can encourage U.S. officials to share their country’s economic and pharmaceutical wealth, Poehlman says.

Most African nations have debt that is higher than their gross national product, dooming them to perennial poverty unless the debt is forgiven. As for pharmaceutical products, Poehlman raises the issue of patents vs. public health. He points to Brazil’s decision to break drug patents and manufacture anti-retroviral agents for free distribution. As a result, Brazil has radically curbed its number of AIDS deaths.

“I also believe that every medical student should have a rotation in Malawi or other developing country to teach them compassion and help them realize just how fabulously wealthy we are,” Poehlman says. “A coordinated effort needs to be made to get students outside the walls of medical institutions.”

Tamara Helfer, MD, an obstetrics and gynecology resident at MU, served two months with Poehlman in Malawi during her fourth year of medical school. She recalls that many patients would come to the hospital only after traditional healers had failed. Too often, physicians could do little more than comfort the dying. “At times, there was so much blood that it soaked through to your underwear,” Helfer says. “But Dr. Poehlman had a wonderful healing hand. He gave more strength to dying patients than I ever could.”

Poehlman’s wife, Betty, assisted her husband when she wasn’t teaching at mission schools. At night, the couple sometimes would deliver babies by candlelight. Such experiences were memorable, but primitive facilities and infection-control practices were dangerous. The Poehlmans had to be treated for possible infection from HIV-tainted blood splashes and needle pricks.

“Malawi is no place for the cautious,” Betty Poehlman says. “On the other hand, I can think of no better place for health workers to learn compassion.”

The Poehlmans’ mission is now shared by their family. Their daughter, a nurse, and her husband, an otolaryngologist, have volunteered at the mission hospital. And the Poehlmans’ son, a medical anthropology student, went to Malawi to write his thesis about AIDS communication through songs and stories.

As for George and Betty Poehlman, they plan to work in Malawi at least two months every year. He’ll take time away from his clinic in one of North Carolina’s poorest regions. Although rural and agricultural like Malawi, Hoke County, N.C., shares few similarities with the African country. “Even the poorest people in America have shoes and clothes,” Poehlman says. “When you look at our resources, there is an abundance available for the battle against AIDS. In Africa, we received so very little. But in Africa, a little can accomplish much.”

Archives | Comments | Home

SUBSCRIPTIONS
Subscribe | Change Your Address | Unsubscribe

Copyright © 2007 — Curators of the University of Missouri
DMCA and other copyright information.
All rights reserved. An equal opportunity/ADA institution.
Published by the Mizzou Alumni Association
Questions? Comments? E-mail comments@mizzoualumni.org

Last Update: March 12, 2007