Sunday, June 8, 2008

Saving Grace

Grace Mathanga is joyously pregnant. She smiles all the time, laughing about the shifting child in her belly who keeps her awake at night. In the past few years her circumstances have improved dramatically. She gave up selling shoes in Lilongwe's bustling market for a better-paid job and moved to a rented house with three rooms instead of two in a pleasant suburb, far from the open sewer and the threatening all-night bar of her former place. Behind the privacy of a cane fence, she grows flowers in old paint and oil canisters. She is proud of the gauzy blue curtain hanging inside the door to keep out flies, and of her wooden bed. She shows off the electricity, turning the light and the radio on and off like a delighted child. Eleni, the niece she brought up in her village after the death of her sister Ulemu, has come to live with her. The serious 13-year-old, ambitious to become a nurse, reads Bible study pamphlets for youth on respecting your body (God's temple) and avoiding HIV.

Five years ago, when we first met, Grace faced the future with stoicism but few smiles. Surrounded by the vibrant activity of Lilongwe market, she told me quietly that she knew she was going to die, as thousands of others would in Malawi. She had HIV, but could not afford the drugs that kept people healthy in the UK. Her first baby had expired in agony at the age of three, the child's throat covered in sores. Her husband died in a TB ward soon after. Grace knew she was destined to follow them.

But a Dutch doctor working in Lilongwe read her story in the Guardian's supplement Saving Grace. Hetty van Dijk sought her out, put her on the drugs and started a charity she called the Saving Grace Foundation to help others like her. And now Malawi's government has rolled out a successful treatment programme.

So at sunrise and sunset every day, Grace takes the tablets that suppress the virus and now, at 34, she is going to become a mother again. Life, for women like Grace in Malawi and all over sub-Saharan Africa where free treatment is gradually becoming available, is beginning to return to a sort of normality.

Yet however good things may now seem, normality for women like Grace in Malawi is as fragile as her outwardly smart new home, where the bricks are already crumbling, and the plaster is preparing to crumble. Houses, like lives in Malawi, disappear into the dust very fast. When things go wrong women in Malawi, uneducated and disregarded, have no place to fall. Last June the Malawian Aids support organisation Grace worked for abruptly stopped paying her salary of 12,000 Kwacha (£43) a month. She had no money for rent or even food. There was no job now for her in the colourful market. Grace found herself in a position familiar to so many Malawian women - facing destitution.

"I had no money, so me, I sit down and think what can I do?" says Grace. She did what women in sub-Saharan Africa do because they have no education, no skills and no status. "I found a boyfriend."

She knew him from the market. He was a businessman, a description given to most men with any money. He sold car tyres. Like her, he was HIV positive, she says. He gave her money for food, rent, Eleni's school fees or to support her sisters in Ben Chauya village, and she asked him to use a condom but, she says, it broke. A while later, she realised she was pregnant.
"Then I wonder, I wonder," she says, hardly able to believe what had happened. "For two and a half months I was worried. But I went to friends and talked. The friends say ah, Grace, don't worry. Everything is the work of God." Now, she says, "I want to have a baby. I have no baby. I'm happy to have a baby." She has not told the boyfriend, who has moved 190 miles away to Blantyre. "I don't want him to know," she says. She wants him to have no call on her. She has another job, with a British organisation working on HIV prevention called Theatre for a Change, who rate her highly and pay her a good wage. Although she says she loved her husband, with whom she grew up in Ben Chauya, Grace has no wish to join the masses of women whose lives are spent in often frightening physical subservience to a man.

"I'm alone, with Eleni. I like to be alone. I don't like a boyfriend. You have a boyfriend because you have no money, but now I'm working at a job," she says.

Her future looks hopeful, but its continuance is pinned to the success of a quixotic effort by the international community to bring antiretroviral drugs (ARVs) to a region of Africa that is often short even of simple antibiotics and painkillers. Malawi now has Triomune, a cheap three-in-one combination tablet taken twice a day, made by the Indian generics company Cipla.

In five years Grace has never missed a pill. Those who said mass treatment of people with HIV in sub-Saharan Africa would never work have been confounded. Like Grace, nearly all stick to the regimen because they understand it is only a fragile lifeline. Failure to take a pill means the virus, never eliminated from the body, can gather strength and overcome the drugs. If the virus becomes drug-resistant, a new combination of drugs will be needed, which in Malawi costs eight times more.

Nobody knows how sustainable the treatment programme across sub-Saharan Africa will prove as resistance inevitably spreads - as it has in Europe and the US - and costs escalate. Few now suggest there is any moral or practical alternative, but the money is proving ever harder to extract from donors. Grace, on ARVs longer than most, has been well, but between December and April, under the stress of pregnancy and inadequate nutrition, her CD4 count (the measure of the strength of her immune system which the virus attacks) halved from 800 to 420. Below 200, her body could not fight off lethal infections. She was told to eat better and luckily now has the money to afford to. Her CD4 has slowly begun to climb.

More and more women like Grace with HIV are becoming pregnant in Malawi. They look well, fit and healthy. You wouldn't know they have HIV at all. And either they want babies or their families expect it of them.

The Guardian, Saturday 7 June 2008

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