Serafina's HIV Clinic Card

The Human Impact of Ending Global Aid

Since The Bad Men canceled international aid and demolished USAID, I can’t stop thinking about the people who will die because of it. From 2011 to 2018, I lived in Iringa, Tanzania, working on HIV interventions. I can’t stop thinking about Serafina (not her real name) and my other friends in Tanzania. The ones living with HIV, their drugs paid for by PEPFAR, by US aid.

The day Serafina showed me her blue patient card changed me. She worked in my household for years, but she was more than that. As I headed to work that day, she didn’t open the gate as usual. Instead, she stood frozen and looked at me, blue card held in front of her at waist height. Because of my work, I knew instantly she was telling me her deepest secret: she was living with the virus. HIV. Serafina had worked for me for six years, and I had no idea. The stigma against the infection was so pervasive in Tanzania that husbands and wives often attended the same HIV clinic, secretly from each other. Unlike in the US, in sub-Saharan Africa, HIV is a heterosexual epidemic; 60% of people living with HIV are women.

“Kamwene,” I said. She echoed, “Kamwene,” a Hehe greeting.

“Oh,” I said, switching to Swahili. “Your clinic card?” She knew that I knew.

“I need your help,” she said with desperate eyes. I flipped to her latest entries: weight, medications, CD4 count. The CD4 count is a marker for how many immune cells you have left to fight infections—bacterial, viral, fungal. A healthy person has 500 to 1,500. Hers said 13.

“That’s impossible,” I said and shook my head. If her CD4 count were that low, she’d be on her deathbed. Or dead. Dipping lower than 200 meant full-blown AIDS. The number on her card had to be a mistake, either a machine or transcription error—and no one had bothered to correct it. Or retest. Or switch her to a different regimen of drugs. The ones she was on clearly were not working. I examined her face; now I could see dark spots, a rash. On her arms and feet, too; an opportunistic infection—she did have AIDS.

“What did they tell you?”

“They said to take my meds every day,” she said. A lecture about adherence. Great. Way to blame the victim.

*****

I ended up moving to Tanzania in 2012 because Zambia is landlocked. Zambia mines 4% of the world’s copper, but it’s 70% of the country’s exports, and this copper has to get to the rest of the world. It goes overland through Tanzania along the Tanzania-Zambian railway and highway.

Rail and road follow a parallel path west, from coastal Dar-es-Salaam, past plains of sisal farms, baobab tree forests, through Mikumi National Park where elephants cross the road, up into the Southern Highlands of Iringa, then south through the vast tea- and timber-producing regions, the dry rice fields, and up again into the plantain-treed hills before reaching the Zambian border. These are the same routes as ancient Arab slave traders, 19^th-century British explorers, then Christian missionaries, and brutal German militaries. Then Greek tobacco farmers, British dairy farmers, White non-profit idealists, heroin traffickers, and Tanzanian villagers.

All of them, like I did, found reason to stop in Iringa for a night, for weeks, for years.

Iringa is on the way to someplace else. The truckers who haul plantains, tomatoes, copper, timber, tea, mining equipment, cars, and packaged goods east and west, north and south along the highways stop at Iringa weigh stations, police barricades, and bustling truck stops encircled by bars and guesthouses. Women—teenage women, village women, women with children, HIV-positive women, married women—surround the men to offer their wares, their services. To wash the men’s clothes, cook their food, ride along to the border, flirt with them over dark bottles of Kilimanjaro lager and sweet Savannah dry, sleep in their guesthouse beds. All for a small fee: two red 10,000-shilling notes, perhaps bundled with a larger fee: a fetus, a discharge, a virus.

This is the road that brought me to Iringa, figuratively and literally—a hired Avis driver navigated the ancient pathway in a white Toyota Prado SUV with my then-husband, my son, and me in the back, marveling at the unfamiliar sights (Did you see that giraffe?!) Over the years, I drove this route back and forth dozens of times, 12-plus hours to travel 300 miles. This highway, this crossroads, these truck stops, these truckers, these women, had caught the attention of the Office of the US Global AIDS Coordinator, and slated it for a $60 million PEPFAR investment into combatting the region’s HIV—1 in 6 adults was HIV-positive.

I was a second-year doctoral student in international public health, focusing on HIV and reproductive health. I spoke Swahili and had already lived in coastal Tanzania for four years. USAID funds sent me to dusty, windy Iringa to help figure out why the HIV rate was so damn high—the highest in the country—and partner with several USAID-funded organizations to do something about it.

The deep history and geopolitical, neocolonial complications of a White, middle-class, highly educated person being flown in (with a shipping container of my household items arriving a few months later, thanks US taxpayers!) to “solve the AIDS problem” are not lost on me:

The East African origins of human life;

The ancient monsoon-wind-directed ocean trade routes that linked the Middle East, India, China, and East Africa before the Portuguese ever arrived;

The brutal trade in human beings;

Christian missionary and colonial upheavals and razing of local socioeconomic structures;

Imports of New World crops and displacement of local, healthier staples;

Rinderpest disseminating cattle and nomadic ethnicities;

The exploitation of local soldiers in World War battles over foreign land;

The political and physical violence in the fights for independence;

Cold War battles for Tanzania’s loyalty and access to natural resources;

The neocolonial structural adjustment plans that damaged education and healthcare;

The racism and structural violence that justified neglect of the continent where HIV/AIDS originated;

The modern import of vehement homophobia by American evangelicals;

The lingering hegemony of whiteness;

Bush’s choice to require PEPFAR funds be used on American-made pharmaceuticals, 1000 times more expensive than the defiant, patent-breaking generics made in India and Brazil;

The federal policy that I fly American, drive American, buy American in a country where, as an American, I was suspected to be CIA, there to undermine local elections.

I knew all this and pondered my place and complicity in all this, and, while drinking South African beer with European expat friends at a restaurant owned by Indians who’ve never been to India, made snide remarks about the USAID stickers (“From the American People”) plastered on every desk, chair, computer, and file cabinet in every public HIV clinic in dozens of countries. USAID had its problems; global aid has its problems, but those funds did save lives. Trump and Musk don’t care. Narcissists only know power and control, not empathy. They probably think Tanzania is part of Australia, where the devils come from.

*****

Serafina is still alive. That day, I transferred her to an Italian-funded clinic that switched her to different drugs and gave her oil, corn meal, rice. “Oh yes, my husband goes to this clinic,” she said. She had a major reaction to the new drugs and spent two weeks in the hospital; her teenage daughter nursed her. Switched to yet another drug regimen, she recovered and regained weight. Her skin cleared up. Sofia, the daughter, equally traumatized and inspired by caring for her mother, studied nursing, then pharmacy.

But will there be any drugs for her to dispense?