THERE’S AN IMAGE that is captured in my memory from last month, when we visited Mauwa health center. We drove past a water pump, one of many in the district where people get their water and then carry it back to their home. At this particular water pump there was a small boy – maybe 5 years old – pumping water into a bucket. It seemed like a game to him as he lifted the lever up and pushed it down, over and over again. And as he pumped away, there was a young girl – also maybe 5 years old – in a simple pink dress, walking towards him. On her head she carried a plastic tub, but she was wearing it upside down, like a hat that was too big for her as she balanced it on her forehead. It was a telling image, knowing that both children would carry the buckets full of water back home on their heads, walking a long distance.

PEOPLE WALK A lot here. In the evening, coming from Blantyre, there are hundreds of people on the road – walking. They walk for miles, carrying children on their backs, water, maize or firewood on their heads; walking to work, school, church or home; wearing shoes, sandals, or simply barefoot. It’s quite a procession, and I never stop wondering where all these people are going, and how much further they have to go. But this is the normal pace and activity of life in the Chiradzulu district of Malawi. People continue to live their lives, though life is changing around them. I hear that the number of cars has increased, since businessmen from the Middle East have brought Toyotas in to sell for about 2000 USD. Of course the number of people is growing too, as are the rates of diseases.

TODAY IS WORLD TB Day (March 24) and TB continues to rampage through the developing world. Can you imagine if 22,000 people had TB in Atlanta? Is that enough to fill Philips Arena? TB continues to devastate families and communities, and it’s gotten worse since partnering with AIDS.HIV/AIDS has really taken a toll on this community, and funeral processions are a common sight on the roads.

HERE IN CHIRADZULU the ARV drugs have had a profound impact and have helped make HIV a chronic disease rather than a fatal one. Yet people still talk about ARV’s as providing a grace period. Most of the drugs we are using to treat our patients are first-line drugs, which means they are the oldest of the drugs available, and thus the cheapest as well as those associated with more side effects. One question to ask is if people could be taking the first-line alternative drugs, or the second-line drugs – more expensive, but fewer side effects. Since ARV’s are a lifetime commitment, the question of cost and adherence is commonly brought up. But then there is also the question of the right to medication. The proportion of patients living with HIV is way higher in Africa than anywhere else. And yet only a small fraction of those affected are taking ARV’s. In the words of an MSF t-shirt, 8000 people will die today from AIDS because treating them is not “cost effective.” So is it really a question of access or is it a question of human rights?

THE LOSS OF a trained or skilled workforce is far greater than any economic cost of drugs or health care infrastructure – just ask the mining companies in South Africa. These companies are now treating their employees and providing prevention efforts, free of charge. They’ve done the math and it’s cheaper to treat their employees than it is to lose them to AIDS.Will HIV/AIDS continue to be the tragedy that future generations will look back on and ask why we didn’t do enough? It’s our own history we are writing. There are plenty of questions to ask; who are responsible for finding the answers?

Sandy, from Chiradzulu in Malawi (photos by Pat Carrick)