"Has he been dewormed?" the doctor asked.
"What? No! Not him, just the cat," I answered.
Doctor Cloete scribbled on his notepad. Without looking up he added: "And tuberculosis? I assume he's been vaccinated?"
Jon, who had only recently turned three, snuggled into my lap. We'd lived in South Africa almost a year and already, Jon had been treated for bronchitis and pneumonia. Although recovered, he still seemed listless, still coughed, still wouldn't eat very much. And no, he had not been vaccinated against TB.
Before we left Canada, I'd taken all three of my boys to a travel doctor who specialized in vaccinations for overseas locations. He'd recommended hepatitis and rabies shots, but made no mention of TB (or intestinal worms, for that matter). Dr. Cloete, examining my lethargic three-year-old, found this odd -- and urgent. During subsequent weeks, through hastily-arranged TB skin tests, vaccinations designed for newborns, and reactions to those vaccines so large and pustular they made me weak, I cursed that travel doctor many times.
As I combed the Internet and spoke with friends in the medical field, I grew even more irate. South Africa, I learned, has the second highest rate of TB infection in the world (next to neighboring Swaziland), over 200 times that of the U.S. And here, TB vaccinations are routine for infants. Why was our travel doctor unaware of this? Why had I been unaware of this? And why is TB, a preventable, curable disease, still killing so many people?
The answer, I came to realize, has much to do with another serious illness -- HIV. I've since forgiven our travel doctor; he's a travel doctor, after all, not a long-term relocation doctor. Perhaps he thought our family, well-fed, healthy expats, would be unaffected by TB. It's true that one third of the global population carries TB bacteria, yet full-blown TB infection occurs in only a small percentage. If HIV is also present, however, TB can be lethal -- and South Africa is home to the world's largest population of people living with HIV, over five million. Tuberculosis has such a strong foothold in this country in part because so many immune systems have been compromised by HIV.
I've heard many South Africans say that they're tired of news on HIV/AIDS, tired of hearing their beautiful, diverse country equated with disease and tragedy. I agree. On the other hand, I cannot live in South Africa, write about South Africa, and not acknowledge HIV, for it continues to shape this society. Here is one more statistic to consider: Thirty percent of pregnant women in South Africa are HIV positive. Think of it. TB is the leading killer of HIV-positive people, and one in three pregnant women is HIV-positive.
So, while I'm thankful that TB and HIV have not affected our family directly (Jon's listlessness was just a cold), I needn't look far to find people -- women, mothers -- whose lives are altered by these illnesses. Last month, I was privileged to meet Nobomi.* Her life involves HIV, but her story evokes neither pity nor dissociation. On the contrary, Nobomi exemplifies the salutary power of shared understanding and experience.
Almost ten years ago, Nobomi became pregnant for the first time, and during prenatal screening tested positive for HIV. She went home terrified, certain that her husband would leave her, that her baby would also test positive, and that she would die before raising her child. Back in 2003, however, Nobomi stood on the cusp of several pivotal trends.
She disclosed her HIV status to her husband. He agreed to be tested and was negative, but rather than flee, he stayed with her. Nobomi returned to the prenatal clinic, and there she met another HIV-positive mother who would guide her through pregnancy, birth, and antenatal care. This woman worked for mothers2mothers, then a newly-established organization with a bold mission -- to prevent HIV transmission from mother to baby -- and a brilliant model. What's the best way to inform and support mothers? We all know: Get mothers together and get us talking.
Nobomi met with her Mentor-Mother (mothers2mothers's term) and her support group each week. "At first I just went for the food," she said. "I was pregnant, I had no job of my own, and I was hungry. They had wonderful meals at those meetings."
But very soon, Nobomi said, she recognized the value of knowledge passed from one mother to another. She learned -- she could see in that room -- that HIV was not a death sentence. By following advice and a medical regime, Nobomi gave birth to an HIV-negative baby. In the ten years since, she has had a second healthy baby and remains with her husband. Her Mentor-Mother changed Nobomi's life, and Nobomi was so impressed she became one herself. Several years later, Nobomi was promoted to Site Coordinator for mothers2mothers and now oversees other Mentor-Mothers. She's in charge of her illness, and has her own bank account, a senior-level job, and a healthy family.
"Am I empowered?" she asked with a radiant smile, and it's impossible for me to imagine this self-assured, articulate woman as anything but.
That day, I met Nobomi at the clinic where she works. The waiting room was full, rows and rows of anxious or solemn faces. Nobomi described to me what the Mentor-Mothers will tell these women.
"First, take care of yourself. If you drink alcohol," she said, "no more. You're a juice woman now."
Nobomi went on to explain CD4 counts through an apt metaphor of armies and generals. She related how it feels to take antiretrovirals and dispelled the many myths around these drugs. She also emphasized the importance of condoms, for both HIV-negative and positive partners, and with a hilarious, Oscar-worthy demonstration, explained how she encourages women to use the female condom.
Through women like Nobomi, I can understand why mothers2mothers has been so successful. Last year, Mentor-Mothers and coordinators across Africa counselled one-fifth of the world's HIV-positive pregnant women, and helped to reduce mother-to-baby transmission of HIV to less than four percent. At Nobomi's site, there has not been an HIV-positive baby born in a year.
I left the clinic that day, drove through the hospital gates and down the stretch of highway to our suburb. My sons were waiting at their school, Jon fighting off another seasonal cold, Thomas with instructions for a nature project due tomorrow, Alex both hungry and desperate to stop at the park. Nobomi's story faded and might have slipped away completely. In a country like South Africa, with so many dire contrasts, it is often easy to cocoon into one's own small world, to believe my problems are mine, yours are yours. I am unaffected. But I cannot forget Nobomi's words or her willingness to share them. For many women and their babies, her words spell the difference between sickness and health. And while I won't pretend to fully understand Nobomi's life or experience, she has nonetheless shown me how personal stories reveal where lives intersect, those points of shared foundation and great strength -- especially when linking mothers to mothers.
December 1 is World AIDS Day.
*I have changed her name at the request of mothers2mothers.