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2 Things Involved

In many rural parts of Africa, people live far from their nearest medical centers and have no means of transportation. This is why groups like Dignitas International are promoting a community-based approach to administering drugs and treatment to HIV patients, a technique that's already paying dividends.

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Produced by the National Film Board of Canada.

Learn more about Dignitas International.

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Segment 1

TITLE
National Film Board of Canada presents The Bicycle
TITLE
1 in 5 people in Zomba District, Malawi are infected with HIV.
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But only 3 in 100 know their status.
PAX CHINGAWALE [Dignitas community-based volunteer]
We are going to see a patient who is very, very ill, but has not been given counseling in HIV activities. Her village thought it was due to witchcraft. So they started consulting traditional healers. The strings around the ankle and the wrists are tied by tradition healers. They believe those will drive out the evil spirits. I have seen many people dying. Unfortunately, it was before the availability of ARVs.
TITLE
Anti-retroviral drugs (ARVs) treat AIDS and are affordable.
PAX CHINGAWALE
It's my job to convince everybody and to tell everybody so that they can go and get themselves tested. We cannot disregard the traditional healers. Three-quarters of the people in this area believe in the traditional medicine. Traditional healers use razor blades for cutting tattoos. It's also a medium of transmission. So we educate these people that they shouldn't use one razor blade for several people. We have to work with them to cooperate with them to advise them that, if they suspect a patient to be HIV-infected, they cannot see that kind of disease. It's better for them to refer back to the central hospital.
BRUNO JAMESON [Dignitas Prevention Officer]
Traditional healers, the chiefs, all the influential people in the community, people that are at the heart of the spread and at the heart of the prevention of the disease, it's a job that really involves the roots of where this epidemic is spreading from.
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Pax rides his bike over 20 km a day seeing patients, from house to house.
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Pax discovers Doreen lying in her hut.
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Her family has disowned her.
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Pax asks for our vehicle to take her to hospital 23 km away.
PAX CHINGAWALE
Doreen's case is worrisome. It's common around the surrounding area that if you are HIV positive, you are sick, they feel you deserve it. It's somehow like a punishment. I feel very sad knowing that I'm also HIV positive, knowing that I could also be facing the same kind of situation.
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Zomba District Central Hospital
DR. KEVIN BEZANSON [Dignitas Head of Mission]
So she's had this wound for three months? Two months? Can she sit ... Can she sit forward a bit? You told her it's going to hurt a bit, yeah? Yeah. Yeah. Sorry, my ... It's straw, yeah, straw-colored. Again, it's typical of tuberculosis. If she had been identified earlier, sent earlier, worked up properly earlier, she'd be on TB treatment. Probably by now we could start her on ARVs.
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Dignitas runs an ARV clinic at this hospital.
DR. KEVIN BEZANSON
We have a team that's working in the clinic. It works ... Everything works imperfectly, but it works. And we have three nurses who are absolutely dedicated. We have two clinicians who are working very hard. We've got 700 people on treatment, 700 people, and not all of them have done perfectly, but more than 600 of those are alive and well.
PAX CHINGAWALE
We had some of them written off as dead. But the ARVs have reversed the situation. There is tremendous change.
TITLE
Timothy is Dignitas' 230th ARV patient.
TIMOTHY [Dignitas ARV patient]
I am one of the beneficiaries of the ARVs. I feel very, very great to be back to my working place. Because I didn't dream of going back to my working place, knowing the situation in which I was. But this time there's a very big improvement.
LUCY [Dignitas ARV patient]
Now I'm looking healthy. At first I was not like this. I was very thin and I was even failing to walk even to uphold myself if I wanted to stand, yeah. But now I can take everything, I eat everything which was impossible for me to eat. Yeah.
ALICE KADZANJA [Dignitas nurse]
When I come to them and I speak to them that I'm also HIV positive, and you know, I carry my drugs in my bag every day and I just pull my bottle ...
INTERVIEWER
Did you tell them about your status?
ALICE KADZANJA
Yes, I did. She knows. You can see, she's laughing. She knows. That was the first thing I told. Now this one, has brought the elder sister to come. Because after seeing me, how healthy I am, then she was encouraged.
PAX CHINGAWALE
Now if we have so many people counseled to go for VCT testing and they do not access the ARVs, it would be disastrous to them. Their hope, only hope of survival, is the availability of ARVs, which are being provided here at the central hospital.
DR. KATHERINE ROULEAU [Dignitas Medical Advisor]
We have a huge role to play in the distribution of ARVs and the treatment of patients within the hospital setting. But in fact what we hope to, what we intend to do is actually bring the care of patients with HIV to the community where they actually live, rather than expecting them to come to hospitals where the resources are so stretched to begin with.
JAMES FRASER [Dignitas Executive Director]
Health care systems on their own will not be able to respond. We have 50 percent of all health care posts there vacant. You have nine nurses in the whole hospital for everything. You have, I think you have one doctor for a whole hospital, a central hospital, a referring hospital for four of the districts surrounding Zomba.
DR. KEVIN BEZANSON
There's no way Dignitas can do this alone. From the village through to here everyone, we have to start working at this together.
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Pax visits another one of his patients at the hospital.
PAX CHINGAWALE
There is a very good connection because Dignitas actually relies on us in the field. And we also rely on Dignitas to assist our patients.
DR. KEVIN BEZANSON
Someone like Pax or the people working with him are in the village. They're the ones going house to house to house to house looking at patients.

Segment 2

JAMES FRASER
Groups that are made of people like Pax are the ones who are actually going to be supporting people in their communities and he actually plays a central role in the model of community-based care.
PAX CHINGAWALE
Since ARVs are supposed to be taken for life, the role of the community home-based care is very vital because we will be looking after these patients right there at home.
TITLE
Pax is responsible for more than 20 villages.
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Dr. James Orbinski accepted the Nobel Peace Prize for Médecins Sans Frontières in 1999.
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Now he is the president of Dignitas International
DR. JAMES ORBINSKI [President, Dignitas International]
I think the next big, important question is community-based care. What specifically can we do to help home-based care workers do a better job? Are there problems with incentives, for example? This is always a problem.
PAX CHINGAWALE
I was coming to that.
DR. JAMES ORBINSKI
I'm sure you were coming to it. [laughter]
VOICE
Just mention the word ...
PAX CHINGAWALE
But the biggest problem with home-based care is the transportation system.
DR. JAMES ORBINSKI
Transportation. If you had one ambulance, one bicycle ambulance, how would you get that to the various places in this catchment area?
PAX CHINGAWALE
In this catchment area, the people would be aware that there is coming the bicycle.
DR. JAMES ORBINSKI
And then they would go to Zomba and you would bring it back.
TITLE
Without a bicycle-ambulance, many patients can't get to the hospital at all.
DR. JAMES ORBINSKI
So are we going in the vehicle now? Okay, let's go. It would be nice if it would be as simple as opening a bottle of pills and giving the person the pill and watching them swallow the pill. That is a very, very important part of community-based care. It's treatment. It's a very, very important part, but it's not everything. It's everything around that. So you already knew that you were getting sick. And your second husband, where is he now?
TRANSLATOR
He's dead.
DR. JAMES ORBINSKI
He's also dead. You've had a very tough time, eh? Over the years. Yeah. So you're very, very precise in terms of when you take your tablets.
ROSALINA [Dignitas ARV patient]
Yes.
DR. JAMES ORBINSKI
And how do you feel now?
ROSALINA [Dignitas ARV patient]
I'm very good.
DR. JAMES ORBINSKI
I'm very good. That's great. That's great. It means building networks of people like Pax. It's really the next big revolutionary idea in terms of containing and controlling the epidemic in a way that respects people. Community-based care is about finding, using, and supporting existing structures.
JAMES FRASER
Everyone has friends, families, neighbors who have died from the disease. What they're doing is they're helping their friends and their families and their neighbors die more comfortably, because they don't have the technology, they don't have the drugs that will actually keep people alive. If we can harness this energy, organize it, train it, and then link it to the health care system, and then we do research so that we can figure out what aspects of the model can we take from Zomba, bring it to South Africa, bring it to India, bring it to Nigeria, wherever. This will be the next key, the next big step forward to be able to increase access to treatment and keep people alive.
PAX CHINGAWALE
Every minute of my life is full of HIV activities and I've seen a change in many people now. They respect me, and they themselves are questioning whether they have HIV/AIDS or not. So there is a very big impact.
TITLE
Doreen died two days later.
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She was 24 years old.
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Dignitas is ordering a locally made bicycle-ambulance for Pax.
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[end credits]