SIHA DISTRICT, Tanzania—Maria Paulo sat on a bench in the middle of the playground outside the children's tuberculosis ward at the Kibong'oto National TB Hospital, adjusting her red shúkà wrap and bobbing her 3-year-old grandson, Musa, on her knee. She had brought Musa to the TB hospital from their Maasai village, after both traditional medicine and a two-month stint in the Monduli District Hospital had failed to cure him. Musa's advanced TB, which Maria said he probably contracted from his father, was diagnosed with an X-ray. "His lungs were black," she said. Treating the Maasai has been a particular challenge, since many believe that AIDS, TB, and other ailments are "not for the Maasai," and so they do not seek treatment until they are very sick, if ever, doctors told me.
The nomadic lifestyle of the Maasai and their trust in traditional medicine hinder attempts to provide them with modern medical treatment. "The situation at the hospital is not like home, but Musa is getting better, so I forget about all my other problems," Maria told me. At home, Maria lives in a polygamist household, but at the hospital she is her grandson's sole caretaker, sleeping on a bed next to him in the pediatric TB ward. The room was airy and bright, with knotted mosquito nets dangling over the bed. Kibong'oto is surprisingly cheery: The lush, well-manicured grounds are bisected by swept red paths and dotted with tidy cinder-block buildings with green metal roofs. The hospital, which has 340 beds, opened as a tuberculosis sanitarium in 1926, when it was thought that the fresh air at the base of Mount Kilimanjaro would heal the patients, who came to the hospital from around British East Africa. "There were no TB meds then," said Dr. Liberate John, the hospital's administrator. "They thought that sunlight would kill the bacilla."
Today, the TB epidemic looks very different. HIV and tuberculosis often march in tandem, with the former fueling the spread of the latter. In 1983, before HIV really took hold in Tanzania, 11,750 people were diagnosed with TB, according to government statistics. Today there are 64,267 diagnosed cases. Together, HIV and TB kill around 91,000 people in Tanzania each year, according to UNAIDS and WHO statistics. In Tanzania, 30 percent of AIDS-related deaths are caused by TB, and some 20,000 TB patients are HIV-positive.
A two-hour drive away from Kibong'oto on the Maasai Steppe, the Mererani Health Center serves the mining town of Mererani, which has a much higher HIV rate than the surrounding area. Anywhere from 50 to 100 patients who have both HIV and TB visit the health center every day, center director Reginald Msaki said. The clinic opened in 2007 and serves as the main health facility for the town of 10,000 people. While most of Mererani's Tanzanite miners come from around Tanzania and East Africa, some are drawn from the local Maasai community. "Some Maasai contract HIV in town and bring it back home, where it spreads among the community like wildfire," Msaki said, blaming polygamy and the Maasai belief that HIV is for the non-Maasai. "The majority believe they can't contract the disease, but those who have been counseled have changed their minds." Mika Parasoi, a Maasai gem dealer interviewed on the dirt road outside the clinic, said no one in his family has ever been tested for HIV. "If someone was HIV-positive, we would prefer to use traditional medicine," he said.
Traditional medicine has an enduring draw; consequently, it is a struggle to convince patients to stick with modern treatment. Standing in a breezy exterior hallway in Moshi's Kilimanjaro Christian Medical Center near the Child Centered Family Care Clinic where he spends his days, pediatrician Dr. Rahim Damji told me that for weeks this spring, the crowds that typically throng the outpatient HIV clinic at the hospital had thinned out. Many patients stopped taking their anti-retroviral medication after making the trek several hours away to visit a new traditional healer in Loliondo, Ambilikile Mwasapile, known simply as Babu. A retired Lutheran minister, Babu began to gain fame around East Africa last fall because of a herbal concoction—called mugariga—that he claims is a miracle cure for HIV and four other major ailments, including diabetes, hypertension, and epilepsy. Lines of SUVs and minibuses crawled along, stretching for miles as people—often very ill—tried to reach him. Some avoided the line by flying in on helicopters. Babu's visitors included government officials such as Tanzania's deputy minister for Water and Irrigation. (Babu even has a Facebook page, where people from as far away as Romania have reached out to him.)
Dr. Maya Maxym, an American pediatrician at Kilimanjaro Christian Medical Center with the Pediatric AIDS Corps, explained Babu's draw: "People here have a very deep faith, and God is very present, real, and tangible in their lives," she said. "So, the combination of religiosity and magical thinking creates a perfect niche for someone like Babu to come in and give people hope that their suffering can be taken away by a miracle." People are willing to shell out two months' salary to "go and drink a cup of hope." The impact on HIV clinics around the area was noticeable. "People were coming here less and less. But now they've learned that these herbal medications are not working and are coming back to the hospital," Damji said. "We have had to change some medication because of resistance."
The Tanzanian government walks a fine line with traditional healers, allowing them now after banning them outright in 2009 after a number of albinos were killed for their body parts, which some witch doctors said could cure HIV. Dr. Deo Mtasiwa, chief medical officer with Tanzania's Ministry of Health, told me that people have the option of visiting traditional healers. "You're allowed to go, but don't hang out for too long. If the treatment is not working, go back and rejoin the modern medicine system," he said, adding that the government requires traditional healers to register with them and evaluates their products for safety. "We don't go into efficacy, but the product must be safe." Some medicine doctors subtly push people toward modern medicine, telling their patients to take some herbs as well as a TB test.
Over the last seven years, treatment has scaled up in Tanzania—in 2004, essentially no one was receiving anti-retroviral therapy, and today more than 270,000 people are taking the drugs. With the arrival of ARVs, the landscape is changing. HIV/AIDS is no longer a death sentence. But the government is having a hard time delivering lifelong care to hundreds of thousands of people.
But new research illustrates the importance of getting as many people on anti-retroviral treatment as possible—provided it can be paid for. A study released in mid-May and funded by the U.S. National Institutes of Health showed that early ARV treatment can severely reduce transmission and drop viral load to undetectable levels. The study followed 1,763 heterosexual couples with discordant HIV status from 2005 to 2010 in Botswana, Brazil, India, Kenya, Malawi, South Africa, Thailand, the United States, and Zimbabwe and found that people taking anti-retrovirals are 96 percent less likely to spread the virus to their HIV-negative partners. The results were so conclusive that NIH opted to end the study four years early. This means anti-retrovirals both treat and prevent HIV. Thanks to treatment and education campaigns, new infections in Tanzania have dropped to 100,000 per year, down from a high of 180,000 in 1993.
While 6 million people in the developing world are on ARVs today, another 9.35 million are in urgent need of treatment. On June 8, U.N. Secretary-General Ban Ki-Moon asked governments to set a goal of putting 13 million people on anti-retroviral therapy by 2015. But, according to Doctors Without Borders, in private meetings, the United States and some European governments have voiced opposition, saying that it's too ambitious a target in the aftermath of this economic downturn. Already, budget shortfalls in Italy have meant the country has not paid the $354 million it committed to the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2009 and 2010, and it is on track to become the first country to renege on its pledge to the organization.
It took five years after testing positive for HIV for one woman I spoke with to visit a medical doctor. Zam Zam Haruna, 35, discovered she was HIV-positive in 2001, after her husband died of AIDS. After her diagnosis, she moved from Tabora, in western Tanzania, to the capital, Dar es Salaam, where she sought out a traditional healer. Despite all the painful injections she received and the many herbal concoctions she drank, she never got any better. Discouraged, she stopped seeing him after a year, but she waited until she was extremely ill to visit PASADA, a Catholic clinic in Dar es Salaam. She began taking anti-retroviral drugs there, and after tweaking the dosages and drug combinations several times, she is now much better and has married an HIV-positive man she met at the clinic, where she also volunteers in exchange for a $90 monthly stipend. When Zam Zam first went to PASADA "she was very sick—dying—but she's much better now," said Jovin Tesha, the clinic's director of counseling.