They Said It Couldn’t Be Done

Nikki Gamer: Hi everyone, this is Nikki Gamer for Catholic Relief Services. And welcome back to Behind the Story, a podcast series that invites you to celebrate the people behind 75 years of our history—the people we serve, our partners, our staff … and especially the supporters like you who make our work possible. In our last episode we spoke to Nathalie and Dave Piraino—both former CRS staff—about the Rwandan genocide that shocked the world in April of 1994 and changed the way we approach our programs in the midst of conflict and cultural tensions. But today we’ll be talking about a time—less than 20 years ago—when people said it was just too expensive …  too risky … too hard …  to stem the deadly tide of HIV and AIDS in sub-Saharan Africa. They said it couldn’t be done. But, of course, they were wrong. We’ll be talking to Michele Broemmelsiek, CRS’ vice president of Overseas Operations, and Dr. Carl Stecker, CRS senior technical advisor for HIV and global health—both of whom were on the front lines of our HIV work … and the impact it had on millions of people. Michele, Dr. Stecker, thank you so much for being with us and for taking time to tell this important story.

Michele Broemmelsiek: Well, thank you, Nikki. I’m really excited to be here.

Dr. Carl Stecker: And we’ve got some great stories we want to tell you.

Nikki Gamer: All right, so we have a lot to cover here, but I want to start with you, Michele. Can you take us back in time to sub-Saharan Africa as we were entering into our HIV work, and can you paint us a picture of what it was like in one of the hardest-hit countries—like Zambia?

Michele Broemmelsiek: Thank you, Nikki. My own story, in my career with CRS, intersected the HIV crisis in the year of 2001. And that was when I moved my husband and my 2-year-old daughter from Indonesia, where I was working for CRS. And I had my first job as country representative in Zambia. And actually, CRS had just opened our office there, and I had to learn on the ground what was going on. And, really, that was an experience of HIV. So maybe to connect the dots between what I saw and what the statistics were at the time … if you can imagine in Zambia, which had a population of 12 million, about that time. It’s a very large country. It’s twice the size of the state of California.

Nikki Gamer: Oh, wow.

Michele Broemmelsiek: So they had every month, 10,000 people dying from HIV. So that was like a 747 crashing every day in that country, every day of the year, that entire year, which led to 120,000 people died that year.

Michele Broemmelsiek: We had about seven staff. Two of us were American and the other five were Zambian. And every week someone on that team had a significant family member—a parent, a spouse, a sibling—die. They were going to significant funerals every week. So in the first year, I ended up attending a funeral. There were a row of people digging graves, and the grave diggers finished a row of graves 12 wide. So the funerals would all start simultaneously at those 12 graves, and they were digging another 12. And this was happening in three or four parts of the same cemetery that entire day.

Michele Broemmelsiek: So one of the reasons so many people were dying is there was no drugs. That means basically you’re just doing care for the sick. And the Catholic Church was really at the forefront … was help people die with dignity. You’re trying to pray with them, but you couldn’t offer them anything other than death.

Nikki Gamer: What does that mean when someone is diagnosed back in 2001? What does that mean for him or her?

Dr. Carl Stecker: I lived and worked in Cameroon, in the Central African Republic, for almost 20 years. And starting in the late ’70s, early ’80s, my wife and I—both as registered nurses—worked as missionaries in health care. In the early 2000s … I come to CRS in 2002 and begin work providing technical assistance to country programs who are struggling, as Michele described, how do we deal with HIV?

Dr. Carl Stecker: And I specifically remember arriving in Entebbe in Uganda, and there’s about a 40-minute drive from Entebbe to Kampala, the capital, where the CRS office was. All along the way were furniture makers making coffins … big billboards, scary billboards about “HIV kills.”

Nikki Gamer: So you go into a clinic back then and you get your blood tested and you’re told, “Yes, you have HIV.” How long from that point to developing full blown AIDS to passing away from this disease?

Dr. Carl Stecker: Test kits didn’t become available until in the late ’90s, and available in Africa until much after that. So you went through everything: It’s not a cold, it’s not the flu, it’s not just diarrhea, it’s not amoebic dysentery. And then you figured out with the combination of many different illnesses—Oh, this is AIDS, acquired immune deficiency syndrome—that this person must be HIV-positive. So then you began to treat what illness you could treat, but then you cared for the person because eventually they were going to die. But there was no cure for HIV. There is no vaccine for HIV. And so this was just hospice care, helping people to die with dignity.

Nikki Gamer: So we think of HIV here in the U.S. nowadays as chronic, but it’s treatable. But back then, it was really a death sentence.

Michele Broemmelsiek: And people would try so hard to do the few things they could to help their family. And so one thing they would do—Carl mentioned that you’d see all these coffin makers. It really was the best income-generating activity you could support people to do … which is, which is horrific because everyone was dying. But people would go out, because they didn’t want to pauper their family, and they would buy their coffin ahead of time. And they would literally sleep on top of it because that was the only piece of furniture they would have left. They knew if they didn’t, the cost to the family would be devastation beyond just the loss of that person’s life.

Nikki Gamer: What did HIV do to families, and then communities? Because I read that once someone was diagnosed, they were literally ostracized or isolated.

Dr. Carl Stecker: Yeah, so we saw shame, discrimination, stigma. We were often within our programs trying to get across the message that the only way that you can get HIV is exchange of bodily fluids. At one point in time in the early 2000s, the 10 countries with the most orphans and vulnerable children in the world were in Africa—all 10 of them having more than a million children that were orphaned.

Nikki Gamer: So Michele, can you talk for a minute about what that does to an economy, or even an entire country?

Michele Broemmelsiek: So we think in our head that this was mostly poor people, and, of course, there were many poor people who had HIV. But really the drivers—the people who are moving around and had multiple partners or were going to school and contracted HIV while they were in school—were people who were getting education. This destructive disease, in and of itself, would have been enough, right? To just, you know, take apart families, take apart culture and society. But on top of that, if you layer the stigma that Carl was speaking of, you know, which grew out of the fact that in the U.S., HIV in the beginning was passed mostly through homosexual contact. So that wasn’t true in Africa.

Michele Broemmelsiek: One of the things that for me was the most heartbreaking, was, building on what Carl said, about the million orphans. You know, the aunts, the uncles, the parents—and sometimes even the grandparents—were dying. You ended up with child-headed households, usually a teenager caring for their siblings. And I visited many of these households where you would have a 13- or 14-year-old taking care of a 2-year-old, trying to get the 2-year-old to hospital because they kept getting sick. So that that sense of the burden and the breakdown of what we even considered to be a family, and the care of a family, wasn’t even happening at the height of the crisis.

Nikki Gamer: Wow. That’s a pretty dire picture. Give me the scope when this was at its worst. What are we talking in terms of number of countries affected and number of people?

Dr. Carl Stecker: The height of the epidemic in Africa arrived in the mid-2000s—2004, 2005—when there were over 2 million deaths a year from HIV on the African continent, estimated, for both of those years each. So 4 million deaths just in 2004 and 2005. A lot of it was in southern Africa, eastern Africa … less so in central Africa, and even less so in West Africa.

Nikki Gamer: Can you tell us: Why did HIV spread in this part of the world in particular … and why so rapidly?

Michele Broemmelsiek: If someone is HIV positive, and they’re driving a truck thousands of kilometers across Africa and they’re stopping multiple times and they have relationships in those communities, then it spreads, right? So those people in those communities may have relationships. So that’s one factor … is the trucking routes. The other is that in southern Africa you have a lot of mining companies, so you have gold mining, diamond mining. So usually men leave their family in Zimbabwe or Zambia or South Africa, Lesotho, Swaziland, Botswana. They go to the mine, and they return home. So while they’re away, they have relationships in that town where they’re living at the mine.

Nikki Gamer: Would you say the Catholic way of approaching HIV… how is that different than what others were doing at the time?

Michele Broemmelsiek: I think that the main response before there were drugs was to encourage people to use condoms. And that was something that the Catholic Church never felt was the right response. We instead added another voice, which is to say, we care about you, we care about your dignity, here’s some other options that we want you to think about—positive living, abstaining, delaying sexual debut and being faithful. And how do you provide hope? How do you fight the fear? I think that the home-based care was one small way, because we could say we are people who care, we will care to the day you die and beyond, we will care about you, we will care about your family.

Nikki Gamer: Let’s talk about the turning point in the epidemic. Dr. Stecker, what was the game changer?

Dr. Carl Stecker: Oh, it was definitely the announcement at the State of the Union address by President Bush in February of 2003 for the President’s Emergency Plan for AIDS Relief, what we call PEPFAR, which announced $15 billion to work over the next 5 years, 2004 to 2008, in what they were calling 13 high prevalence, or high priority, countries. By Thanksgiving Day of 2003, we had the announcements of two large global grant opportunities that were only open to those organizations that could respond in at least three different countries. And then on World AIDS day, December 1, 2003—so just less than a week later—the large announcement on the availability of antiretroviral therapy. So when the announcement was made in 2003, we had the availability of a cocktail of drugs—and the U.S. had already been treating with three drugs and finding very good results.

Dr. Carl Stecker: I think one of our biggest challenges in thinking about providing antiretroviral therapy was that it’s not a cure. It’s like high blood pressure, for which you’re taking some medication for the rest of your life. And while there’s $15 billion available over the next 5 years, how are we—as Catholic Relief Services, involved in HIV in many countries around the world—going to start somebody on antiretroviral therapy knowing that the funding might end after 5 years? We knew that we couldn’t meet the criteria on our own. And so we had to create a consortium of partners at a central level. Then to propose that we would work in a number of those 13 high priority countries that would become PEPFAR countries.

Nikki Gamer: Can you tell us a little bit more about some of the obstacles to addressing this epidemic? I would imagine even basic infrastructure … like hospitals … were not in place in many of these communities.

Michele Broemmelsiek: They’re not like the hospital that we imagine. They’re very modest, you know, maybe around 50 beds. The doctors have no experience with HIV or AIDS. The nursing staff have to know about how they care for these patients. If you went into a hospital at the beginning of the rollout of treatment and you asked to see their records, they would often tell you they had no records. Or you’d go into their record room and it would just be stacks of pieces of paper that didn’t have a filing system—and in treating HIV, you cannot do that.

Michele Broemmelsiek: You also have to have a pharmacy that functions. In addition, you had to have a lab that had to run lab tests using the latest technology and the latest laboratory equipment. You’d have to have the support of the government to make sure that all of these pieces came together. There were some hospitals in Zambia that didn’t have any electricity or running water. So the fundamental step wasn’t, “Can I get them the lab equipment?” It was, can I get them water and electricity so that they can serve all of these hundreds of people who are dying in their community.

Michele Broemmelsiek: But it was amazing what that team did. And everyone was there because they really wanted to end AIDS. We had partners on the ground where we knew that there were good, strong hospitals that we could develop. Even if they didn’t have everything in place, we knew we could build their capacity because the vision from the beginning of the proposal design was that we wanted to end this project by handing it over to local organizations.

Nikki Gamer: What was it like to be out on the front lines of this epidemic at that time? And then when you’re working around the clock trying to build this thing, what was that like for you and even your families?

Dr. Carl Stecker: We quickly put together three startup teams and went out concurrently. And over a period of 3 months, we went to nine countries and made the initial contacts with, or the subsequent contacts with, all of the in-country partners, with the ministries of health, their national AIDS control councils, with the U.S. government entity that would be overseeing our work in the country. We met our targets of putting over 14,000 people on treatment in the first year, which doesn’t sound like very much. But to start up in nine countries—really, it was huge. We met our second-year targets as well, and had over 40,000 people on therapy at the end of year 2. And then it just exponentially, you know, developed after that. Personally, and with my family, I was gone almost 70% of the time. Sometimes at the drop of a hat. I remember a Thursday afternoon getting called from the Centers for Disease Control in Atlanta saying,“There’s a meeting in South Africa on Monday morning at 9 a.m. You need to be there.”

Nikki Gamer: Michele?

Michele Broemmelsiek: I was experiencing this whole rollout from a different seat on the field side, of getting the team together there. You’re in an environment, as we talked about, of stigma and fear. And yet now if there’s treatment—that’s a totally different world. So, you started to see people accepting the possibility that there might be light at the end of this tunnel instead of death, right? That there might be life. And that’s why you do it.

Nikki Gamer: So, is there a story that particularly stands out for you about the importance of this project and the real impact it had … or maybe even continues to have?

Michele Broemmelsiek: One of the project directors said, “I just had a meeting, I need to tell you about it. I went to a community meeting and there was a mother there with her daughter.” And the mother’s name was Frieda and she was dying from AIDS, and her daughter was on her lap and she was called Pretty, and she said it was true. She was this beautiful, pretty child, and the mother said, “I’m going to die. How is this program going to take care of my child?” And that, that sense of like, wow, that’s all we can say is we’re going to do our best to help you take care and to have a good death. This was before treatment and, and then to have that image of that mother who loved her child beyond measure and could only imagine,“What’s going to happen to my child? I don’t care about myself. What’s going to happen to my child?”

Nikki Gamer: Carl, I want to turn to you for a minute. What story drives the impact home?

Dr. Carl Stecker: I remember Bridget came from Zambia. She had lost her husband to HIV, discovered that she herself was HIV positive, got very thin. We saw a Lazarus effect. And what we mean by that is that people were sometimes literally brought into the hospital or the institution in a wheelbarrow. And you would see them up and walking and go back to work. She was a schoolteacher.She is one of those people that had that experience of the Lazarus effect—of being really, literally brought back to her former life. But she continued on, to provide home-based care and to be a treatment buddy to other members in her community that were living with HIV … to be an encouragement for them,that they needed to take their drugs everyday.

Dr. Carl Stecker: We brought Bridget over to be a spokesperson for AIDSRelief, coming from Zambia. And she was here for a month, and she went and spoke in several parishes and dioceses at meetings. We also took her down to Washington and introduced her to decision-makers of whether PEPFAR would continue or not.

Michele Broemmelsiek: I would, I would say if I was thinking about the impact and what I’m taking away from this, this experience of working on this amazing effort of AIDSRelief. I feel like at the end of the day, we can imagine the end of AIDS if we treat at least 80% of the people in a country who need treatment. If you get a certain percentage of your population on treatment and virally suppressed, you no longer have an epidemic. And what can we imagine? Africa without AIDS. The world without AIDS. That’s possible.

Michele Broemmelsiek: They said it couldn’t be done.And why don’t we believe in an AIDS-free world, even if it’s hard? But I think that this is the kind of work that CRS is about. And this is why we should continue to believe that it can be done.

Nikki Gamer: It sounds like there’s still a lot of work to do.

Michele Broemmelsiek: Definitely.

Dr. Carl Stecker: Yes.

Nikki Gamer: Thank you both so much.

Dr. Carl Stecker: Thank you, Nikki. It was really good to relive some of that experience. It really was an amazing time—and being in the right place at the right time with the right people and the right organization to lead and do this. It was an amazing thing to, to have a role in eradicating AIDS.

Michele Broemmelsiek: I’m so happy to have had the opportunity to hear Carl’s story and to tell the story of what happened with AIDS relief at CRS.

Nikki Gamer: It is hard to believe, but we’ve come to the end of our year-long journey celebrating 75 years of CRS history through our Behind the Story podcast series. And I’m truly inspired by all we’ve learned through 12 podcasts and 75 years of compassion, partnership and solidarity that define who we all are as part of the CRS family. And I hope you have too.

Nikki Gamer: But we’re not done yet … not even by a long shot. We have a little surprise for you. We thought: What better way to wrap up a year-long journey through our history than to take a look at what awaits us in the future? So we’re putting away our way-back time machine and taking out our crystal ball … with an extra podcast … it’s a bonus that will feature CRS President and CEO Sean Callahan. And he’ll be talking to us about his bold new vision for 2019—and way beyond—to create real and lasting change for the world’s most vulnerable people.

Nikki Gamer: Be sure to check it out on 75.crs.org. Or search “CRS 75th Anniversary” on iTunes to download all your favorite episodes. And from all of us at CRS, we wish you all a very Merry Christmas and all the best in the 2019! And don’t forget to keep an eye out for what’s next!