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In Botswana, Step to Cut AIDS Proves a Formula for Disaster

Promoting Formula

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The vast diamond reserves in this landlocked southern African nation have allowed Botswana's government to build a safety net unmatched on the continent, offering its 1.8 million citizens cradle-to-grave support for education and health care. And though it has one of the world's highest rates of HIV, with one in four adults infected, it has some of Africa's most celebrated programs to combat AIDS, including effective measures to prevent mothers from infecting their children during pregnancy and birth.

The country was also a pioneer in the international drive to protect babies at risk of becoming infected through breast-feeding. In 1997, the United Nations began urging new mothers with HIV to use formula wherever supplies could be provided safely and reliably. Botswana, with an extensive public water system, good roads and a legacy of competent governance, joined the UNICEF-led effort and agreed to pay for the program as a standard service to new mothers.

There were skeptics. Some international public health experts, including Coovadia, cautioned that few Africans had the means to prepare formula in a sanitary manner -- a process that requires access to clean water, utensils, formula powder and heat for sterilization.

And even for those who could make formula safely, some experts warned, breast-feeding's other health benefits could not easily be replaced. A study by Coovadia and other South African researchers published in the medical journal Lancet in August 1999 found that breast milk alone, when not mixed with other foods, was no more likely to infect children than formula.

But Botswana's health officials were determined to begin the programs. In a recent interview, Health Minister Sheila D. Tlou angrily recalled a conference of international policymakers in Montreal a month after the Lancet article appeared. Some favored urging mothers with HIV in rich countries to use formula while telling those in poorer, less-developed ones to breast-feed.

"We saw red!" Tlou said. She recalled asking other participants in the meeting: "Why are you sentencing all of our children to death? And why are you sentencing all of us to psychological damage in knowing that we were the ones who infected them?"

The program started slowly because few women were willing to be tested for a virus that at the time was a death sentence. But as Botswana expanded the availability of antiretroviral drugs, which can dramatically extend and improve lives, HIV testing gradually became routine for pregnant women.

Those with the virus received a series of antiretroviral pills in the final weeks of their pregnancies, and their newborn children received a dose of syrup laced with another powerful anti-AIDS drug in their first hours of life.

The rate of HIV among babies born to mothers with the virus fell from 40 percent in 2002 to 6 percent. Demand for the free government formula soared.

Among the beneficiaries was Mavundu. She didn't have reliably sterile utensils or a stove, as U.N. agencies envisioned in their policy statements. But she did have access to firewood for cooking. And the seemingly clean water that flowed from a communal tap was just an eight-minute walk from her compound, consisting of round, dirt-floor huts and a fenced yard that she shared with her family and its livestock, including packs of voracious chickens.

Unusually for rural Africa, there was also a government clinic nearby and, she was told, a reliable supply of Nan, a popular formula marketed by the international food group Nestlé, to keep her playful, chubby-cheeked son strong and healthy.

But it was a promise, Mavundu soon discovered, that the government was unable to keep.

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