The nondescript town of Maun in northern Botswana is often no more than a way-station on the road to the luxury safari camps of the Okavango Delta, a haven for wildlife and one of Africa's most popular tourist destinations.
For Hilary Fairclough, a former nurse from England, a visit to Maun while accompanying her partner on a work trip in 2000, planted the seed of an idea that has brought her back twice a year since then.
She was stunned by the toll HIV/AIDS was taking on the Batswana, at a time when antiretroviral (ARV) drugs had yet to become available in the public health sector, and in 2002 she returned to find out if there was a demand among people living with HIV for her services as a trained homeopath.
Very few homeopaths practice in Botswana, and not many people in Maun had heard of this alternative form of medicine before her arrival, but the Maun Homeopathy Project, as it later became known, has since treated 1,500 HIV-positive people in the area.
The service, which is free thanks to donations from the project's supporters in the UK, is provided by two volunteer homeopaths she recruits from the UK to spend three months at a time in Maun.
Many of the project's patients are now taking ARV medication, but report that the homeopathic remedies help them deal with the sometimes unpleasant side effects as well as opportunistic infections and depression, and improve general wellness.
"It's been really welcomed," Fairclough told IRIN/PlusNews. "People have been very open. I think they feel supported by us because we listen, but I believe the medicines also really help people."
The homeopathy debate
Despite being around for over 200 years, the efficacy of homeopathy is still being debated. Supporters of conventional medicines tend to view it as a placebo at best and quackery at worst. In an opinion published this week in The Star, a South African daily newspaper, Mark Colvin, a doctor and epidemiologist, described homeopathy as based on "an absurd premise" that has never been scientifically substantiated.
Homeopathy's supporters respond that homeopathic medicine operates so differently from conventional medicine - treating the whole person rather than just their illness - that the conventional means of measuring effectiveness are inadequate.
Fairclough, who practices homeopathy in the UK when she is not doing fund-raising and administration for the project in Maun, is dismayed to have been drawn into the controversy after the project was mentioned in several opinion pieces in the UK press during December 2007.
The media debate was sparked by a London symposium on the homeopathic response to HIV and AIDS, but the question of whether or not public health services such as the UK's National Health Service (NHS) should fund homeopathic treatment was also raised. NHS funding for two homeopathic hospitals has since been cut.
"I think it's a very small number of people who are anti-homeopathy in the UK, who have a powerful voice," Fairclough said. "Here [in Botswana], people feel there's room for different approaches."
She believes part of the appeal of homeopathy in Botswana is because it has elements of both traditional and western medicine. "It comes in a pill, but the approach - taking into account mind, body and spirit - is more Batswana. People are very comfortable with it," she said.
It depends on the individual
Kelebogile, a slight woman in her late forties, has been a patient of Fairclough's since 2002. She began taking ARVs in 2003, but still takes what she calls "the small pills" because they have helped her with "many problems".
Consultations are held at the the Lutheran Church in Maun, where the project runs a twice-weekly clinic. Kelebogile's consultation lasted about 30 minutes and did not include a physical examination.
Photo: Hilary Fairclough/MaunHomeopathyProject
Hilary Fairclough visits one of her patients at their home.
"You don't give the same medicine to everyone who has HIV," Fairclough said. "It depends on the individual - what stresses or traumas they might have, and how they react to their life situations."
She selected three different bottles of pills from her case of remedies and dispensed a few of each into plastic bags: one for Kelegobile's ailment, one for her emotional state and the other to help stimulate her immune system.
Overstretched health service
To understand why patients queue up outside the Lutheran Church, sometimes travelling from villages several hundred kilometres away, one has only to look to Botswana's overstretched public health service.
Like the homeopathic remedies, ARVs are free in Botswana, but with a national HIV infection rate of 24 percent, second only to Swaziland, the need is overwhelming. Just as the government has sought to expand access to ARV treatment, doctors and nurses have been leaving the country to take better-paying jobs in South Africa and other neighbouring countries, or even in Australia and the UK.
"At the moment, we have five doctors and we're supposed to have 13," said the chief medical officer at Maun Hospital, Dr Richard Kambinda. The hospital's HIV/AIDS clinic is supposed to be staffed by three doctors, but Kambinda said it was lucky if it had one at any given time. The machine used to establish the CD4 count, which determines when a patient should start taking ARVs, or how well they are doing on treatment, has been broken for several months.
"In the hospital they don't ask so many questions, they do everything quickly," Kelegobile commented. "They only give you painkillers, always painkillers."
Botswana's ARV treatment programme has often been cited as a model for other countries in the region, but some people, including the hospital's former chief medical officer, Dr Eric Beltz, believe it has sacrificed quality for quantity.
In the hospital they don't ask so many questions, they do everything quickly ... They only give you painkillers, always painkillers.
Beltz, who moved to Australia three years ago but was visiting Botswana when IRIN/PlusNews spoke to him, worries that the rapid scale-up of the HIV/AIDS treatment programme, combined with the shortage of staff to monitor drug adherence and treatment failure, will create significant problems with drug resistance in the not too distant future.
His concerns are shared by Israel Tjiharuka, who runs a counselling centre for people living with HIV in the village of Sehitwa, about 100km from Maun, where the homeopathy project runs an outreach clinic once a month.
"In our hospitals the doctors are busy - they'll just refill [ARV prescriptions], they won't ask any questions," he told IRIN/PlusNews. "People aren't educated about what side effects they might experience on certain drugs, so they don't complain."
Although Sehitwa will soon get a clinic that will dispense ARVs, at present villagers still have to travel to Maun to pick up their medicine. Adherence was a problem, said Tjiharuka. "Sometimes people don't have money to go to Maun, so they stay without."
During a recent visit to Sehitwa, Fairclough was asked to make a home visit to Nabebeng, 44, a woman who has been on ARVs for two years, but is now bedridden. She was hunched under a blanket outside her home, the several layers of clothing she wore despite the heat not enough to hide her too-thin frame. "I feel hunger, but my heart does not want to eat," she told Fairclough.
Nabebeng had begun experiencing pains in her side and in her legs when she started taking ARVs, but when she told staff at the hospital they only gave her painkillers. Fairclough prescribed a remedy for liver toxicity as well as a "grief remedy" to help her cope with her boyfriend's death the week before.
Although Fairclough regularly treats patients for side effects from ARVs, she is careful to describe homeopathy as "complementary" to ARV treatment. "I've had a couple of patients say they just want the homeopathy, but I say 'no, it's not enough, you need the ARVs'. It might be that homeopathy could keep people from needing ARVs for longer, but we can't afford to conduct that kind of research."
Future plans
Alex Sarefo and Wasanapi Kapii, two young men working with the project as volunteers, translate for the homeopaths but eventually hope to conduct their own consultations. With a view to future sustainability, the project is funding them to complete a three-year UK-based long-distance course to qualify as homeopaths.
"At first I was so sceptical, until I saw the changes happening in patients, and then I started reading up on it and understanding the science behind it," said Sarefo, who started helping at the project after taking a break from his medical studies in Zimbabwe
Kapii hopes to open his own homeopathy practice after he qualifies, while Sarefo talks of starting a homeopathy school and advocating for the wider use of alternative medicines like homeopathy. "There's no prejudice here towards alternative medicine and I feel it has to be kept that way."
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Theme(s): (PLUSNEWS) HIV/AIDS (PlusNews)
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