'What’s true of all evils in the world is true of plague. It helps men to rise above themselves.'
–Albert Camus, The Plague
When I walked into the Intensive Care Unit of the local hospital in Ramotswa, Botswana, I knew she was deteriorating fast. The patient was a 55-year-old woman who had been admitted over the weekend with pneumonia after not taking her HIV medications for several months. She was now my responsibility as my patient, and it became clear to me that she was likely suffering from pneumocystis pneumonia or PCP, a virulent form of pneumonia seen in people with AIDS. Standing in the ICU, I was calculating what my options were. The only significant difference between the ICU and the rest of the hospital was having oxygen available, but I soon realized the oxygen tank was empty. As the minutes passed, she looked as if she was struggling harder and harder to breathe, and I knew she was dying before my eyes. I called for help, but every salvage attempt we tried failed. After several minutes of resuscitation, her heart stopped because of her inability to breathe, and she died. This was the first time I had ever seen someone die of AIDS.
I am an aspiring doctor finishing up my fourth and final year of medical school. I first became interested in Internal Medicine when I was in middle school and learned about the HIV epidemic in the United States. I was deeply affected by the courage of a community that faced stigma and inexorable death with dignity and a call to action. The role of the physician as potential partner and advocate influenced my career choice to this day. But as a medical student in America in 2016, I see very little HIV, and when I do, it is almost always well-controlled. That is what was so shocking when I came to Botswana, where people regularly died of AIDS-related complications.
When you initially walk into hospitals in Botswana, it is easy to be struck by what is missing. There are no private rooms, no monitors that display the patients’ vital signs at all times, no sense of white sterility that is the status quo in many American hospitals. Instead, there are large, open rooms with patient beds adjacent to each other. There is less visible urgency from practitioners or patients, who will often stay in the hospital placidly for several days at a stretch. One is spared the harangue of beeps and buzzers that form a dissonant soundtrack in American hospitals, and no one complains about the hospital food because their families bring them their meals during visiting hours every day. What is also striking is the number of young people in the hospital, most of whom are HIV-positive.
In a country where the HIV prevalence is 22 percent, making it the third highest in the world, it is assumed that everyone in the hospital is HIV-positive until proven otherwise. This feels so different from the US, where the HIV prevalence is 0.4-0.9 percent. However, Botswana has a national healthcare system, where citizens pay around two dollars per day while in the hospital. Also part of this package are free, first-line antiretroviral medications for any HIV-positive patient in the country. This is an amazing privilege, but a conundrum that confused me. If patients have access to the HIV medicines, then why are people still dying of AIDS-related complications? This question does not have an easy answer, and there are undoubtedly many factors at play. Despite my inability to save my patient as I may have been able to in a hospital in the United States, what became clear was that her death was not simply a matter of what resources were available to me that day. She died of PCP, which could have been easily avoided with antiretroviral medications. Speaking with her family after her death, it became clear that it was the stigma she faced on account of being HIV-positive that had caused my patient to default on her medications. This is a component for the countless others who are admitted to the hospital for complications associated with AIDS in Botswana and elsewhere around the world.
When I think of HIV in the world today, I see progress. I see a disease that was once a death sentence that, when treated, is transformed into a chronic disease that does not decrease your life expectancy. In Botswana, I saw a country with amazing people who were devoted to fighting a virus that continues to take the lives of young people. I also see an illness that continues to devastate communities because of shame and stigma, an obstacle that is difficult to overcome. My time in Botswana reaffirmed my desire to work in the fight against AIDS, but it also made it clear that having the requisite medical knowledge is not enough. As a Student Global AIDS Campaign fellow this year, I will use advocacy and grassroots organizing to mobilize resources for the HIV response, to fight for continued access to affordable medicines and to combat stigma both in the US and abroad. I hope others will join me in this fight.
Rebecca Abelman is a fourth year medical student at the University of Pennsylvania, and a Student Global AIDS Campaign Fellow.