Life and death in Botswana: How immigration status affected my HIV/AIDS patients

As a doctor treating HIV/AIDS patients, I did what I could do, what I had to do — one life at a time

Published August 17, 2018 7:00PM (EDT)

HIV-positive patients attend a class at the Princess Marina Hospital in Gaborone, Botswana, June 26, 2003. (AP/Themba Hadebe)
HIV-positive patients attend a class at the Princess Marina Hospital in Gaborone, Botswana, June 26, 2003. (AP/Themba Hadebe)

Excerpted with permission from "One Life at a Time: An American Doctor’s Memoir of AIDS in Botswana" by Daniel Baxter. Copyright 2018 by Skyhorse Publishing, Inc.

For eight years, Dr. Daniel Baxter, a general internist and HIV specialist from New York City, lived and worked in Botswana, a sub-Saharan country that had one of the highest rates of HIV infection in the world. Dr. Baxter assisted the country in rollout of its National HIV/AIDS Treatment Programme, the first such initiative on the continent, which ultimately was responsible for saving over one hundred thousand Batswana from AIDS.

During his sojourn in Botswana, Dr. Baxter taught thousands of local healthcare workers the basics of HIV medicine, mentored physicians in the clinics, taught medical students and residents on rounds at Princess Marina Hospital (the country’s major referral hospital), served as advisor to the Ministry of Health, and volunteered at Holy Cross Hospice, a struggling day care center for patients with AIDS and terminal cancers.

After returning to the William F. Ryan Community Health Center in Manhattan, where he now works as a front-line primary care physician, Dr. Baxter has written an eloquent and powerful memoir of his work in Botswana, which is a tribute to the legions of patients he cared for there, most of whom faced the terrors of AIDS with grace and faith, their oft repeated “But God is good” giving comfort both to themselves and to Dr. Baxter.

* * *

Long considered a tourist destination for watching wild animals, Botswana has always been a place most Americans have heard about but few can pinpoint on a map. Indeed, when I was first contacted about a job there in 2002, I had to pretend I knew where it was, before quickly searching for it online. The first internet entry I found explained why Botswana had always been so easy to overlook: it’s the size of France, landlocked, and mostly desert—the Kalahari comprises 70 percent of it—and it’s one of the most sparsely populated countries in the world. Its 1.6 million people are a million less than the population of Brooklyn. Initially, the article was at best routine, and reminded me of my soporific eighth-grade geography class in Ohio so many years ago. Routine, that is, until the very end, where a brief paragraph mentioned the AIDS epidemic unfolding there: no less than 24 percent of Botswana’s people were reported to be infected already with HIV, then the highest rate in the world after Swaziland, a smaller country to the south. Life expectancy was projected to plunge by twenty to thirty years by mid-decade. I already knew that all of sub-Saharan Africa was in the crosshairs of the HIV epidemic, but as an AIDS doctor in New York City, I should have known these sobering statistics without the help of Wikipedia. Being slightly hermetic, an African version of Switzerland, somehow hadn’t spared Botswana from the plague.

Sight unseen, I immediately accepted the job.

However, geography books and online articles rarely can capture the real sense of a place, especially Botswana, where I soon realized that one had to look upward to the heavens to counter the very distinct plainness—and too often a mantle of sadness—at ground level below. The blueness of the Botswana sky is unique, a hue unlike any other in the world. Adjectives like limpid, crystalline, and cerulean come to mind, but even these words cannot convey the awesome blue infinitude of the firmament overhead. This immensity of time and space can easily overwhelm someone unaccustomed to it. But for me the predictable mid-afternoon advent of Botswana’s clouds added welcome texture and reassuring dimension to the endless expanse of sky.

As I would discover, Botswana’s cumulus clouds were unfailingly exuberant, fat, if not downright bodacious, unlike the smudged cirrus variety usually brooding over the skyline of New York City. An endless armada of fluffy galleons floating serenely across the sky, at times so close to earth you felt you could almost touch them, Botswana’s clouds seemed unconcerned with the desperate struggles for survival playing out beneath them, struggles in which I soon found myself, both physically and existentially, enmeshed. Later in the afternoon, these frigates would coalesce into thunderhead behemoths of biblical proportions, stretching to all corners of the compass, as if poised to do combat against one another. But at sunset, they would rapidly fade into a flat, pinkish haze, to make way for the moon and star-bejeweled sky of night. At dusk I would often sit out alone on my porch, reflecting on the patients I had seen that day …

Eunice, a Holy Cross Hospice patient who needed a residency permit so she could continue her HIV treatment in Botswana and not be deported to her native Zimbabwe…doctors are supposed to be honest and truthful, but what if being truthful would result in irreparable harm?...

Mercy, the clinic nurse who had “a great pain in my heart” over unwelcome news, quietly divulging her anguished decision so her partner wouldn’t abandon her and her five children…and as with so many of my patients, she concluded her sad story with “But God is good”…

The thirty-two-year-old prisoner, essentially a gasping skeleton, gingerly carried into the clinic by his worried cellmate, and the terrified gaze of their robust guard, who seemed to see his own fate from the contagion wracking his charge…

”No Fear,” a rude guy at my gym, at first my nemesis and then my ex-nemesis, whose gradual descent was halted by my gruffly shouting out to him one day…

Godwill, a frightened illegal Zimbabwean with severe shingles and AIDS, sheltered by his church in the rural Kalahari, and cared for by a clinic nurse, who, breaking government rules concerning non-citizens, answered to a higher authority…

There would be patients I feared I might have harmed…

Comfort, an emaciated ten-year-old girl in the capital’s slum…had my overly attentive care—and hubris—hastened her demise?...

Polite, my maid…did my standoffish reticence, borne of America’s obsession about HIV confidentiality, cause the turmoil she was enduring, making her fear that she was “killing” her newborn baby boy?...

And there were those whose extremity, for reasons I could never fully articulate, transfixed me, evoking my deepest hopes and fears…

Precious, a Holy Cross Hospice patient teetering on the edge of the abyss, alone in her Old Naledi hovel—I really, really wanted her to make it, yet was terrified that my intense hopes would provoke the indifferent fates to strike her down…she should have been “just another AIDS patient”…

Grace, panting into her oxygen mask as her pneumonia threatened to pull her down…she seemed fearful of leaving this earth, whereas her ward-mate Charity, also with a serious pneumonia, didn’t seem to care if she recovered or died…

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Isaac, a fourteen-year-old slowly sliding into the grave as he languished in Marina Hospital, pining to return to his sister in their remote village in the Kalahari...his suffering evoked both nothing and everything from me…you really can’t tell a fourteen-year-old he’s dying from AIDS…

Dolly, twenty years old, raped by her pastor at age thirteen, dying alone at Marina, who finally opened my eyes to the universality of our suffering…

And on and on. Almost every evening, sitting on my porch in the gathering darkness, I would reflect upon the doomed and the spared, the procession of patients with their unfathomable woes flashing before me. In the distance would be the staccato hooting of the red-eyed dove, solitary and cautionary in its plaintive call, reminding me that I was inescapably and, at times, inexplicably in sub-Saharan Africa.

Wikipedia—indeed, my thirty years in medicine—had never prepared me for such things.

Safe Transit Papers

I really didn’t know much about Eunice, who was sitting across the desk from me in the consultation room at Holy Cross Hospice. Spread out before us were her expired immigration papers and a government form that would ultimately determine whether she stayed well or succumbed to AIDS. Although uneducated, she knew their importance, and nervously focused her gaze on them, as if they might be a talisman or tarot cards foretelling her fate.

Eunice was Zimbabwean, and at the time in legal limbo. Her Botswana residency papers had expired several months before. Puso, the Hospice nurse, had given me an explanation as to how it really wasn’t her fault, how her travels back and forth to her family in Zimbabwe had somehow caused her residency permit here to lapse. But I really wasn’t interested in the details. Probably in her fifties but appearing much older, she had previously worked as a maid for an elderly Canadian couple, but when she fell ill from AIDS six months ago, they let her go, an all-too-common occurrence here. To be fair, the Canadians had initially taken her to their private doctor, who prescribed HIV drugs. But their beneficence for their worker of many decades was quickly exhausted, and they turned to the Hospice for help, since, as a non-citizen, Eunice couldn’t get care at the government clinics. Probably because the couple were long-time parishioners at Holy Cross Cathedral, the Hospice took Eunice on board, and for several months it had been paying for her medicine, about four hundred pula, or forty dollars, a month. No longer allowed to live with the Canadians—they quickly replaced her—she had been sharing accommodation with someone from her church. In Botswana, Eunice had two strikes against her: she was Zimbabwean and she was HIV-positive. Actually, three, if you count her being a woman. Add abject poverty and no job, and the impossibilities of her situation multiplied further. The Hospice was her only hope.

Eunice’s situation was not unique. Foreign nationals, whether here legally or illegally, were ineligible for medical care in the clinics. If they ended up hospitalized, they had to pay upfront the costs of any X-rays, blood tests, and medications. The only exception was if they had TB—its public health risks justified treatment for everyone infected. But everything else was out of pocket—cash or no care. The government’s reasons were clear enough: if medical care were free, as it was for its citizens, the steady stream of illegal immigrants from poorer neighboring countries, especially Zimbabwe, would become a flood of biblical scale. But at Marina Hospital, where every week or so a Zimbabwean would be admitted for complications of AIDS, it was difficult trying to treat a very sick patient who couldn’t afford the X-rays, CT scans, and blood tests necessary to diagnose their conditions, plus the cost of any medications. More often than not, the best we could do was give them bus fare for a one-way ticket back home, where they’d probably die. The medical care in Zimbabwe was much worse than any place in Botswana.

The situation was even more dire for HIV-infected foreigners imprisoned in Botswana’s jails and prisons. In 2014, two HIV-positive Zimbabwean prisoners sued to be given HIV drugs. When BONELA, a local human rights organization and a constant thorn in the government’s side, won the case in the High Court, the government refused to enforce the ruling while they strategized how to make an appeal. Imagine the US Department of Justice flouting an order from the Supreme Court. Moreover, as a member of the Southern African Development Community, Botswana was obliged to provide such medical treatment to prisoners who were foreign nationals. As elsewhere in Africa, the government was selective in what laws and court orders it obeyed, especially when it involved HIV and outsiders, especially Zimbabweans. One of the legacies of the British was an arcane, byzantine legal system that allowed lawyers to delay, prevaricate, procrastinate, appeal and re-appeal, re-litigate, re-re-litigate, and otherwise thumb their noses at High Court rulings, especially if the government had decided to ignore its judgments. Government lawyers, as they often are elsewhere, were highly skilled at delay, obfuscation, and interminable appeals.

Zimbabweans were generally regarded here as leeches, taking up Batswana jobs. Worse, they were classified as potential criminals, guilty until proven innocent. Whenever there was an armed break-in of an upscale house or a brazen, broad-daylight hold-up at a busy restaurant, blame was automatically placed on South Africans and Zimbabweans. Ever since President Mugabe had reduced his country to a basket case, Botswana and Zimbabwe suffered very poor relations. Police would regularly round up illegals, primarily targeting businesses with day laborers. Those without proper papers were arrested and shipped across the border. My own experiences with Zimbabweans was completely at odds with the prejudiced stereotype many people here had.

Today at the Hospice, Eunice needed a residency permit so she could return to Botswana whenever she visited her family in Zimbabwe. If she couldn’t re-enter Botswana, legally at least, she couldn’t get her HIV medications from the Hospice. I had seen her only once before, when she first became a Hospice patient after starting her HIV treatment. She needed blood tests then to verify that the drugs were working, but neither she nor the Hospice could afford them. I paid for the tests, which showed that her T-cells had passed above 200, the magic number that often separated the doomed from the spared. Today she seemed fine, certainly not as desperate as many Hospice patients. As before, she said little, and replied in the negative when I asked if she was having any symptoms. A diminutive, withdrawn lady with rotting front teeth, she had coal-black skin, and was wearing a bright calico dress, her balding head covered by an equally colorful bandana.

I poured over her papers. There were several prior residency permits, yellow and fragile, from when she had been a housekeeper, as well as her worn but thankfully current Zimbabwean passport. Among the scattered documents was a recent letter from the Hospice’s social worker attesting that she was under our care, and was in the process of renewing her residency permit. Hopefully, if she were stopped by the police, the Anglican diocesan letterhead might convince them to let her be, at least for a while. The immigration form I was expected to fill out was fairly brief. Several questions dealt with her mental capacity, using quaint terminology held over from the British many decades previously: “Is the applicant an imbecile?,” “Is the applicant a moron?,” and “Is the applicant a cretin?” Probably somewhere in government statutes there was detailed description of what differentiated an imbecile, a moron, or a cretin, but I knew she was none of the above.

Towards the bottom of Eunice’s form was a more serious question, highlighted in bold print and underlined: “Has the applicant ever tested positive for the HIV virus?” Yes, AIDS apartheid. Since her last residency permit, she had come down with AIDS. Until recently, it had not been illegal to discriminate against citizens—citizens—who were HIV-positive, and even though an anti-discrimination law was now on the books, it didn’t pertain to non-citizens like Eunice. Answering this question in the affirmative would sink her chances of a residency permit and continued access to her HIV medicines. Maybe I was imagining it, but I felt the intensity of her stare on my hand, my pen poised over two boxes marked “Yes” and “No.” Beneath this last question, right above the signature line, was the Physician Attestation Statement which ended with an ominous warning, capitalized and again in bold print: “FAILURE TO ANSWER ALL QUESTIONS TRUTHFULLY IS PUNISHABLE BY LAW.”

Annoyed, I leaned back and stared blankly at the paper. It had been an excruciatingly hard morning of rounds at the hospital, and I relished the chance to put my brain on hold for a few seconds. A warm breeze rustled the window curtains. Birds were singing outside, and a red-eyed dove softly hooted from a nearby tree. Puso was sitting in a corner, perusing messages on his cellphone. In the distance, probably arriving from Johannesburg, a propeller plane, likely filled with businessmen and tourists, lazily droned on its final descent to the airport. I briefly wondered if it was Air Botswana or South African Airways. I sighed again and took a deep, meditative breath. I refocused on the form, hesitated briefly, and then ticked one of the two boxes. I signed the form with a flourish, adding my cell number and credentials as a Specialist Physician and Lecturer at the School of Medicine. The Batswana, especially the bureaucrats, were impressed by titles, and the University of Botswana was especially respected. Gathering her paperwork into a crumpled envelope, Eunice got up and left, saying nothing and not stopping to review the completed immigration form.

“The social worker will take her to Immigration on Monday,” Puso volunteered.

Several weeks later, Puso told me that Eunice’s residency permit had been approved for another two years.

We do what we can do, what we have to do—one life at a time.

By Daniel Baxter

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