A Way to Foster Employee Health

JWANENG, Botswana -- The digging does not stop. Not when night falls or when a three-year drought sears the countryside or when the nation edges toward famine. Workers for Debswana Diamond Co. have not stopped digging for 20 years, scooping out enough wealth to make Jwaneng the world’s richest diamond mine and Botswana’s economy one of the fastest-growing in southern Africa.

Gems, and the miners who dig them up, are building the nation. So when the death rate among Debswana’s 6,000 employees doubled in five years and nearly a third of the workforce -- including 18% of its executives -- became infected with human immunodeficiency virus, the company took an unprecedented step. In 1999, it began offering voluntary testing for HIV, which can lead to AIDS, at mining operations around Botswana.

“We decided that AIDS was the biggest threat to our business,” said Assistant General Manager Sebetlela Sebetlela. So last year, Debswana became the first company in Africa to give HIV-fighting anti-retroviral therapy to its employees, he said.

“It wasn’t just that we wanted to be good,” he added. “We realized that unless we did something, we could have had a situation where production came to a halt.”

Acquired immune deficiency syndrome is beginning to take an economic toll on sub-Saharan Africa, hindering the region’s efforts to lift itself out of poverty.

Companies in the region are reporting increased absenteeism and rising recruitment and training costs as AIDS-stricken workers sicken and die. Studies have shown that businesses are spending six to 10 times as much money on HIV-infected employees as on healthy workers. Production losses so far have been modest, but they are noticeable and deepening.

Sub-Saharan Africa is the focal point of the pandemic, according to a United Nations report released last month. In the hardest-hit countries -- Lesotho, Swaziland and Zimbabwe -- one of every three residents has HIV. Of the 3.1 million deaths due to AIDS this year, 77% have occurred in sub-Saharan Africa.

In a recent speech in Johannesburg, South Africa, Stephen Lewis, the U.N. special envoy for HIV/AIDS for this continent, said the pandemic has devastated the region’s agricultural sector and is driving a food shortage that is putting 15 million Africans at risk of starvation.

Botswana’s Affluence

Botswana has the region’s highest per capita income and one of the most stable governments, having avoided the civil wars and the harsh colonial rule that its neighbors Zimbabwe and South Africa endured. But Botswana’s relative affluence and progressive health policies haven’t protected it from the pandemic; nearly four of 10 people in this nation of 1.6 million are infected by HIV.

With the beef industry suffering because of parched grasslands, diamonds -- especially the ones from the Jwaneng mine -- are all that stand between the country and ruin. Profit from Debswana’s mines is fueling Botswana’s economy, which is expected to grow 9% this year, up from 8% in 2001.

The company, which is jointly owned by the government and DeBeers, has set a powerful example in the region by offering to cover most of the cost for employees’ anti-retroviral drugs, which attack HIV. This year, the government also started giving out anti-retroviral therapies at four hospitals. About 3,000 people are receiving the life-saving drugs, and the government plans to open four more dispensaries next year.

“Debswana is the model for our country,” said Dr. Banu Khan, head of Botswana’s AIDS programs. “Anti-retroviral therapies will lead to AIDS prevention, they will prevent children from becoming orphans, they will prolong life.”

Botswana’s programs became feasible only after pharmaceutical companies reduced prices for AIDS medicines -- sometimes by as much as 90% -- after a clash last year with several African countries. New drugs with fewer side effects and simplified regimens also helped.

A Lesson for S. Africa

South African companies have watched Debswana and Botswana’s government for two years, and now dozens of businesses -- including multinationals such as DaimlerChrysler, Coca-Cola and Barclay’s Bank -- are offering anti-retroviral treatment along with AIDS awareness programs.

“We’re stepping in because the government isn’t,” said Errol Sackstein, general director of pen manufacturer Bic South Africa.

It took an international outcry before the South African government acknowledged the link between HIV and AIDS and realized that anti-retroviral therapies are the country’s best hope of mitigating the pandemic. But there still is no plan to provide the drugs on a wide scale.

The examples set by Botswana and the private industry are inspiring, said Dr. Ayanda Ntsaluba, head of South Africa’s public health department. But they are of little use to his country, which has the world’s greatest concentration of HIV cases: about 4.7 million people, nearly three times Botswana’s entire population.

Recent legislation will sharply increase South Africa’s health budget over the next three years, but the country still cannot afford to offer AIDS medicines to its people, Ntsaluba said.

“We do not have a big enough pool of physicians fully trained in the use of some of these drugs,” he said. “We have good hospital facilities, but if we started concentrating on this, we would have to convert all of them to AIDS treatment hospitals. They would be overwhelmed.”

Ntsaluba pointed out that businesses are treating “captive populations who have to show up for work every day” whereas “our patients often disappear, go to their villages and then come back after a month or two.”

Company programs are working with people who are employed, he added, but half of South Africa’s 43 million people are indigent. Many could not even afford to meet the requirement that some drugs be taken on a full stomach.

Debswana’s financial success here has built a town of 16,000, where 20 years ago there were only scrub brush and herdsmen’s scattered round huts. Now Jwaneng has a modern town hall, a country club and row upon row of brick hovels for miners and tract developments for executives.

There also is a state-of-the-art hospital, which next year will distribute anti-retrovirals for 60,000 people in the area.

Brian Brink, senior vice president of mining conglomerate Anglo American, said he recognized the “monstrous challenge facing government in dealing with people who are unemployed, have poor nutrition, no sanitation, lack housing.”

“But you can start,” he said. “And I would argue that you could begin with the economically active people that you need to keep the country moving.”

Providing AIDS therapies was a simple matter of enlightened self-interest for his company, Brink said. This year, executives at a subsidiary, AngloGold, estimated that AIDS was costing $9 for each ounce of gold mined. Brink said about 33,500, or 25%, of the company’s southern African workforce is HIV-positive.

“When you have people getting sick and dying from AIDS, when you’ve got sickness and death all around you, when you’re going to funerals every weekend -- all these things are going to have a negative impact on morale and productivity,” he said.

Who Gets the Medicine?

As welcome as these corporate AIDS programs are, they are not without moral ambiguity. Debswana, for example, offers anti-retroviral drugs to its employees and to one spouse for each.

“They believe that is enough to give the medicine to a worker and his wife,” said Topo Autlwetse of the Botswana Mining Workers Union. “But here in Botswana some men will marry more than one wife. And what about the children?”

Marriage itself can be hard to pin down in a country where matrimony often leaves no paper trail.

Debswana machine operator Ishmael Time is taking anti-retroviral drugs, but his “permanent girlfriend” is ineligible.

“I tell her that she should get tested,” he said. “But she says it will do no good.”

Bic’s Sackstein noted: “A lot of workers say they don’t want the drugs if they are going to live and their spouses and children are going to die. We’re finding that some workers are getting the drugs and giving half of them to their spouses and children. That way no one benefits from the drugs.”

Most private programs only provide anti-retroviral medicine to employees as long as they are working for a company. Laying off or firing an HIV-positive worker could be tantamount to a death sentence.

Some companies report low levels of participation in programs because of a lack of awareness and fear of discrimination.

The stigma of HIV is perhaps more intense here than in the United States; even people with obvious symptoms of full-blown AIDS tend to deny they are ill. And there have been reports of companies firing sick workers.

Economists have found evidence that some firms have reduced their pension funds and health benefits to avoid payouts to AIDS sufferers. One study reported anecdotal evidence in Zimbabwe of firms testing applicants for HIV.

Sean Jelley, a consultant on corporate AIDS programs, said businesses face a stigma too. Some corporations avoid tracking HIV rates or making them public, he said, to protect their brand and retain skittish investors.

Amalgamated Beverage Industries, a 4,500-employee South African Coca-Cola bottler, has an anti-retroviral program that covers each employee and three dependents. But company policy prohibits public disclosure of the HIV rate among its workers.

“We haven’t even disclosed that to our shareholders,” said Lindi Oberink, strategic affairs manager. “We’re trying to protect our employees and our company against the stigma.”

Debswana was among the first businesses in the region to announce its infection rates, but only 20% of its HIV-positive workers have enrolled in its program.

Accepting Help

Time, the machine operator, is one of the brave few at Jwaneng who have come out publicly about their infections.

There was a time when he could scarcely hide it. Until getting on a triple therapy program, Time was frail, covered in painful lesions and taking lots of sick days. At one point, supervisor Mooketsi Seragi was so worried that he ventured to pry: “Mr. Time, you’re losing weight. Is it due to the fact that you’re not happy at work?”

“No, I’m fine,” Time lied.

Several months later Time gathered enough gumption to get an HIV test at the Jwaneng Mine Hospital. He took the results to Seragi and said he wanted to quit working -- and maybe even living.

“He said he wanted to commit suicide,” Seragi said. “I sat him down and told him that I accept him exactly how he is, so he should accept himself. Then I thought to myself, ‘What am I going to do about the rest in the group?’ I didn’t want them discriminating against him or treating Mr. Time with suspicion. I had to manage the attitudes and emotions of his co-workers.”

Judging from the reactions of people as Time walked around Jwaneng, Seragi was successful.

“Hey, Mr. Time, where are you coming from, looking so fit?” a female worker said, flirting.

Time does look healthy. His appetite has returned, and he supplements his diet with vitamins and a regimen of immune system enhancers: three tablets in the morning, four at night. He stopped drinking and smoking. No sex either. Most days, he is back in front of his diamond sorting machine.

“I want my peers to see me and to know that AIDS is manageable,” he said. “I will work until I decide to retire.”