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In The Midst Of Sickness
HE IS STANDING BEFORE ME, THIS MAN WHOM I barely know, the employee of somebody I have met. It is a cold day—cold, at least, by the standards of Botswana, although the sky is clear and the air is bathed in sunlight. "How are you now, Rra?" My question makes him shake his head. "I am not well. I cannot eat. I am weak, weak." There is silence. What is there to be said? The gulf between us seems as wide as the very Kalahari: I am a visitor from the impossibly rich West, somewhere far away, in his eyes protected by ethnicity and passport from the fate that he sees for himself. This is, of course, nothing unusual for those who venture into regions of sickness, but the experience, for all its commonness, is, nonetheless, brutal. The contrast could hardly be greater: the sick and the well; the rich and the poor. But then, a year later, I am back, and I see him again, rather against my expectations. In an epidemic, people are there, and then, quite suddenly, they are no longer there; one stops being surprised. He has put on weight. He is smiling. There is an energy about him. "Feeling better now, Rra?" "Oh, I am strong now. Strong!" Now he has some sense of a future. For the wife and two children whom he lost to AIDS, the antiretroviral drugs that the government of Botswana makes available to its citizens, it is too late, but not for him. He is a good patient and complies religiously with the drug regimen prescribed for him. For a man living in one squalid room and struggling to make a living, it cannot be simple, but he takes his drugs on time and goes to the government clinic when required. In difficult times, a story like that—repeated thousands of times in Botswana today—is one of the cheering tales from a time of sickness. But behind these positive stories there is a hinterland of suffering that has traumatized Africa’s most successful country, Botswana, which is typical of what has been felt by many countries in the two decades and more during which HIV has cut its swath through sub-Saharan Africa. For me, as a novelist whose books—not as part of any concerted plan on my part—have been viewed as an introduction to a previously not very well-known country, the issue has been this: what should I say about AIDS? What role should AIDS play in a fictional account of the life of a country in the throes of the illness? Is writing about Botswana without mentioning the AIDS pandemic like writing about London during the Blitz without mentioning the fact that bombs were going off?
I FIRST STARTED TO VISIT BOTSWANA IN 1981, when I was spending some months working in nearby Swaziland. The following year I worked in Botswana itself and began what turned into a long emotional and literary conversation with that remarkable place. I remember being struck at the time by the optimism of the country. Botswana was doing well: revenues from the well-regulated diamond industry were being applied to the task of building up the country’s infrastructure. Money was being poured into education and health, and the benefits of this investment were everywhere to be seen. From the health point of view, Botswana was in an enviable position when compared with many other African countries, where health spending was, from economic necessity, pitifully low. At that time a physician friend, Howard Moffat, was running a small hospital in a town called Mochudi, about twenty miles north of the capital, Gaborone. He was optimistic and felt that there was a good chance that the country could bring tuberculosis under control with its well-funded program of residential treatment. Bid the sickness cease, said Rudyard Kipling, and it looked as if this goal was at last achievable. Then the disaster occurred. The reasons for the prevalence of HIV in sub-Saharan Africa are complex, but in Botswana, as elsewhere in the region, important factors in the spread of infection were rapid urbanization, improved roads and transport, and the boost given to casual sexual relations by growing prosperity and social mobility. By stealth the disease extended its hold, embarrassment and denial proving strong allies of the virus. In Western societies accustomed to the frank discussion of sexual matters, we often fail to understand the earlier reluctance to talk about HIV in many African countries. People simply did not like to talk too openly about sex, just as North Americans were reluctant to do in the more prudish decades before the 1960s. Only later, when the mortality rate became blindingly obvious, did African leaders begin to use the rhetoric of disaster, as Botswana’s then-president, Festus Mogae, did in his address to the United Nations in 2001, when he famously said: We are threatened with extinction. People are dying in chillingly high numbers. The use of the term extinction might seem extreme, as demographers point out that the effect of a high rate of HIV infection is merely to slow population growth rather than to wipe out whole peoples. But the rate of infection was certainly enough to prompt the government to institute a raft of emergency measures. The resulting battle against HIV/AIDS, conducted on many fronts, including the educational one, has begun to have an effect on the overall incidence, even if today about one in four adults in the country between the ages of nineteen and forty-nine are infected with HIV, according to United Nations estimates The implications of such an infection rate are heartbreaking and can be brought home at unexpected moments. Two years ago I was invited to address a class of teenagers at a Gaborone high school. They were an engaging audience, with the characteristic politeness and attentiveness of the Batswana. Yet as I stood there, looking at my youthful audience, the unwelcome thought came into my mind: one in four of you, perhaps one in three, will have your lives blighted by AIDS. And if you were in neighboring Zimbabwe, where access to antiretroviral drugs is beyond the dreams of most, the conclusion would be even more bleak. There the equivalent thought would be: one in four of you are likely to die before reaching thirty.
FOR AUTHORS, THE PORTRAYAL OF ILLNESS might present something of a dramatic opportunity. Sickness heightens the dramatic tenor of life, underlines the fragility of our existence. In Death in Venice by Thomas Mann, the main character Gustav von Aschenbach’s vision of beauty is rendered the more poignant by the presence of cholera; in Ernest Hemingway’s Snows of Kilimanjaro, the hero’s life of action is brought into sharp relief by the fact that he is on his deathbed; and in Somerset Maugham’s The Painted Veil, the husband’s moral seriousness, as contrasted with his wife’s fecklessness, is demonstrated by his engagement with a raging epidemic. There are many other examples of novels where the reader’s emotional attention is engaged through the portrayal of illness as an inevitable, limiting factor of human existence, something that will test the resources of the protagonists and bring out, as often as not, their finer qualities. Illness can thus become metaphor in the novelist’s hands. There is a genre of Western fiction in which Africa is made to stand for all that is irrational, violent, and ultimately destructive. Joseph Conrad’s Heart of Darkness is an epitome of such novels—a journey into dark regions, culminating in a vision of horror. More recent examples, including some of the sparse, haunting works of South African writers such as John Coetzee or Damon Galgut (whose particularly fine novel, The Good Doctor, is set on Botswana’s borders), create an entirely believable, bleak world inhabited by stranded, lonely people. Human illness in such a world might easily be developed as a metaphor for what is wrong with society; the corruption of the body, AIDS, is a perfect accompaniment to the corruption of the whole state, of venal officials, of grasping politicians, of violence-crazed warlords. When I came to write The No. 1 Ladies’ Detective Agency and the nine novels that followed that first book in the series, I was faced with the task of writing truthfully about a society that was tragically afflicted by the biggest public health disaster of the twentieth century. In writing these novels, I did not want to fall into the trap that awaits any outside writer writing about sub-Saharan Africa, that of seeing only the problems that beset that part of the world. I considered Botswana to be a generous and morally admirable society, one that had set its face against intolerance and human rights abuses and that had, to a very large extent, lived up to the ideals espoused by the country’s first president, Seretse Khama. This is a positive story, intended to show people that life in an African country is not necessarily "nasty, brutish, and short" but is very similar to life anywhere else. In other words, I wanted to show that people widely seen in Europe and North America as "the other" were, in fact, exactly the same as anybody else in their desire to lead good and satisfying lives. But what if at the heart of such a society, normal though it might want to be, there is a devastating illness? It was clear that if AIDS were to be placed at the center of the novels, then that would render them tragedies, and the Heart of Darkness prophecy would be fulfilled. This would also present Botswana in a light in which it did not want to be presented. Nobody likes to be seen as ill, and this applies as much to individuals as it does to whole societies. This is, of course, a question of stigma, and although it is true that stigma is ultimately defeated by honest acknowledgement of the stigmatizing condition, this admission needs to come from the afflicted themselves rather than from outsiders. There is all the difference in the world between being outed and outing oneself. On the basis of my regular visits to Botswana and my conversations with people there, it seemed to me that what people in Botswana wanted was to get on with their lives in spite of the high death rate that had punched a hole in virtually every family in the land. If this attitude had been accompanied by individual denial and a failure as a society to act to contain the pandemic, then nobody could connive in such an approach. But it was accompanied by concerted public campaigns and, although not perfect, by a degree of willingness to change behavior. In light of this, it seemed to me important that one should respect the suffering and grief of a society and tread tactfully. AIDS need not be ignored, but it could at least be mentioned in such a way as not to suggest that this was a sick society: it was a normal society in which some happened to be ill.
AIDS CREPT INTO THE BOOKS THEN, though in a discreet fashion. Mma Ramotswe, the central character in the saga, has an assistant, Mma Makutsi, whose brother, Richard, is clearly dying of AIDS, even if the name of the illness is not mentioned. At the end of the day he is given tender care by a nurse from the Anglican hospice, who dresses him in a clean shirt, "so that a poor man might leave this world in dignity and light." His death is represented, then, as an occasion for the display of human kindness and love, rather than a triumph of disease. At another point in the novels, a clergyman preaches a sermon in the presence of Mma Ramotswe, commenting on our duty not to turn away from the suffering caused by AIDS, a theme that Mma Ramotswe herself dwells on, in a more general context, at various points in the narrative. We cannot walk away from suffering, she says; we simply cannot. And walk away is exactly what many people and organizations have not done, least of all Americans. The story of the United States’ involvement in the battle against AIDS in Africa should be a matter of pride to Americans, even if it is not widely known by the general public. On my regular visits to Botswana I have been struck by the extent of American assistance in public health endeavors throughout the country. The partnership between Merck and Company, the Bill and Melinda Gates Foundation, and the government of Botswana saved many lives through the use of drugs donated by Merck. Then there is the extraordinary contribution of the School of Public Health at Harvard University, which started a partnership with the Botswana government in 1998 and has set up a state-of-the-art HIV research laboratory in Gaborone. This effort, led by the indefatigable Harvard virologist Max Essex, has brought the impressive resources of frontline U.S. research right down to where the battle is being fought on the ground in southern Africa. Elsewhere, throughout the country, one encounters numerous American doctors and nurses giving their time to helping people afflicted by the disease. To good effect? Yes. Slowly, painfully so. According to the United Nations, the rate of infection in pregnant women seems to be receding. In 1990 life expectancy was forty years; by 2007 it had risen to fifty. In recent years Americans have become accustomed to disapproval and even hostility abroad. Mma Ramotswe, were she to be asked about this, might well beg to differ with that view. I cannot speak for her, of course, merely being her creator, but I suspect that she is unlikely to forget this story of help given in a time of sickness.
Alexander McCall Smith was born in what is now Zimbabwe and educated there and in Scotland. He is best known for his Botswana-based No. 1 Ladies’ Detective Agency series, which has been translated into forty-five languages and recently became a television miniseries in the United States and United Kingdom. He is also the author of four other series: 44 Scotland Street, the Isabel Dalhousie novels, Corduroy Mansions, and the Portuguese Irregular Verb series. McCall Smith has written more than sixty books, including specialist academic titles, short-story collections, and a number of children’s books. For many years he was a professor of medical law at the University of Edinburgh, where he is now a professor emeritus. He lives in Edinburgh.
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Portraying Illness
Not Turning Away From...
