Charity begins at home - Mike Hart & 'Grace'

I visited Standard Chartered Bank in six African countries in the spring of 2003. At every stop, my first request was to be introduced to an employee of the Bank who was living with HIV/AIDS. Why? Because HIV/AIDS is the greatest threat to the health and welfare of all Africans. It's also the greatest threat to the businesses and institutions that employ most Africans.

Standard Chartered Bank has more than 5,000 employees throughout Africa and plays a critical role in the commercial life of 13 African nations. The Bank has been aware of the threat of HIV/AIDS for some time and has been working hard to develop strategies to address the issue.

The level of awareness of HIV/AIDS and the approach to the treatment of HIV/AIDS in each country I visited is at a different level of development. In large part this is because the disease has appeared in each country at a different time and spread through the population at a different rate. No two countries in Africa are at exactly the same state of infection or affection.

My last stop in Africa was Nairobi, Kenya. As was my custom, my first request was to be introduced to someone living with HIV. The official national infection rate in Kenya is approximately 10 per cent. Most say the infection rate is much higher. It's certainly higher in the countryside where the populations of whole villages continue to be wiped out. The Bank has approximately 1000 employees in Kenya. At least 100 must be living with HIV. So where were they? And who were they?

I was told that it was highly unlikely that anyone would speak to me about their HIV status. In fact, it was unlikely that anyone would even admit to testing positive for the virus. Why? There are two fundamental reasons for such denial--and they are the same reasons in each and every country I visited in Africa. The first reason is emotional and involves family and society. The second is practical and concerns livelihood and material security.

If you are female and test positive for HIV, you will be labelled `a bad woman', a woman of loose morals who sleeps around, no matter how you may have picked up the virus. If you are male and you test positive for HIV, you will probably have picked up the virus from an extra-marital affair or from a prostitute. These are the social stigmas of carrying the virus.

If you are a married man and you are HIV positive and you don't wear a condom, your wife will become infected. If your wife is pregnant or nursing a child, she will pass the virus to her child. To inform your wife that you are HIV positive is to admit to infidelity. Not an easy thing for anyone to do. These are the familial consequences of carrying the virus.

In purely practical terms, the greatest fear of testing positive for HIV in Africa is the loss of one's job. (A very real deep-seated concern no matter what the Bank or any other employer may say to the contrary.) If your wife leaves you because of infidelity, you can still feed and clothe and provide shelter for her and your children. But if the virus also costs you your job, you're no good to anyone. Not only that--you're alone. Rejected by family, isolated by society, poor and condemned to a miserable, lonely death. What kinds of choices are these? Impossible choices. More significantly, they're paralysing choices. The consequences of either are so onerous that doing nothing actually makes the most sense. And therein the problem.

In every country in Africa I visited, each and every employee I asked feared that they would lose their job if they were found to be HIV positive, this in spite of stated assurances from the Bank to the contrary. At the very least, they would be denied a promotion, or a raise, or the opportunity to apply for another position within the Bank. This is what they believe.

Fortunately, Titus Mutiso, Head of Corporate Affairs in Kenya, and his colleague Doreen Kanyua found someone who was prepared to speak to me. Her name was Grace. (She has asked that we not use her real name. She is still uncomfortable about coming out publicly about her condition.) Doreen would accompany Grace to the interview. Grace was very nervous about talking about her condition. She didn't want her colleagues at the Bank, or her superiors, to know how sick she was. More importantly, she didn't want them to know that her illnesses were the result of the HIV virus. She was terrified of losing her job.

Doreen and Grace arrived shortly after noon. Grace is a tall woman with glasses and short hair. I could see that she was not well. She was extremely thin and walked with careful, measured steps.

Grace has been with Standard Chartered Bank for 17 years. She works in the Bank's main branch in downtown Nairobi. Grace earns approximately US$533 per month (Kenyan Shillings 40,000). She is a single parent, and the sole supporter of two young children. Grace first tested positive for the HIV virus in 1998. She was tested for the virus because her health had begun to fail.

Shortly thereafter, Grace began taking the antiretroviral medication. Grace said that she felt the effect of the medication almost immediately. She said that within 48 hours, her energy and sense of well-being was almost completely restored. Unfortunately, Grace had to pay for the antiretroviral medication herself. The medication is not covered by the Bank's insurance company.

Grace pays US$11 per month to participate in a health insurance plan (almost 2 per cent of her gross monthly salary). All employees are obliged to participate in this programme. However, the insurance company does not cover the cost of antiretroviral medication or the treatment of opportunistic illnesses resulting from HIV.

A month's supply of the least expensive antiretroviral medication costs approximately US$80 (Kenyan Shillings 6,000). Imported antiretroviral medication produced by major international pharmaceutical companies costs US$106 (Kenyan Shillings 8,000) per month per patient. (Prices for antiretroviral medication in Africa vary from country to country. In Botswana, the government supplies the medication free of charge. Throughout Africa, year on year, prices continue to fall.)

Over the past two years, Grace has spent at least US$200 per month on health care--almost 50 per cent of her gross salary. She said that all of her savings were depleted and that she has borrowed heavily from her family. She wondered why someone in her position could not opt out of the Bank's health insurance plan, especially since it does her so little good?

Grace stopped taking antiretroviral medication late last year as she could no longer afford to pay for it. Grace's family all know about her illness. When she is sick she borrows money for medication and to pay for her children's needs.

Grace has not told her children that she has HIV. She feels that they are far too young to understand and that her son would be shattered to know that his mother has such a disease. I asked her why she has not discussed her condition with her superiors at the Bank?

"I am frightened of talking to them at the Bank about my illness. I am frightened that I would lose my job if they found out I have HIV." I asked her if she knows of any other employees who are HIV positive?

"Yes, there are three or four at our branch that I am sure have the virus. I have not talked to them about it, but they have been sick and have lost weight and I'm sure it is because of HIV...I also heard about another young man--he was twenty-nine or thirty--he was transferred to Nairobi last year. He was quite brilliant and was being fast-tracked. But he was quite sick. You could see that he was very sick. And he had no money for the antiretrovirals. He didn't want to apply to the Bank for a discretionary loan because he would have to say what he wanted the money for. He wanted the money so that he could buy the antiretroviral medication. He was in and out of the hospital quite a few times last year. He couldn't afford the drugs and so he died. He was quite brilliant and would have gone very far in the Bank..."

I asked Grace how she manages to keep herself well enough to work without the support of the antiretroviral medication. She said that it takes all her energy to make it in to work each day. She has little energy for anything else. She does the best she can for her children, but knows that she is not able to give them the time and attention they deserve.

Grace's greatest fear right now is to fall ill and be admitted to the hospital. She has told her family that she does not want to go to the hospital again. If she becomes critically ill, she will stay at home. She has decided to die in her own bed.

"I am frightened that I would lose my job if they found out I have HIV."

At this point, Doreen interrupted and explained that Grace was recently released from the hospital. While in the hospital, Grace was served with a letter from the Bank's insurance company saying that they were no longer prepared to pay for her health care. If she couldn't raise the money herself, she would have to leave the hospital. Fortunately, the Bank stepped forward and paid the hospital charges of approximately US$500.

Grace's monthly salary is approximately US$533 (Kenyan Shillings 40,000). Approximately 15 per cent of her gross salary (US$80) is deducted for personal income tax. US$11 is deducted for health insurance. A two bedroom flat in a lower middle class area of Nairobi costs approximately US$200 per month. On top of these expenses, Grace has been spending approximately US$200 per month for the past two years on supplementary health care. This leaves her approximately US$42 each month to pay for food and clothes and basic necessities for herself and her two children. And that doesn't even begin to address her debts--the money she's borrowed from her family and the money advanced by the Bank. No wonder Grace has decided to refuse treatment the next time she falls ill. Of course the irony, or the tragedy, is that if Grace had been taking the antiretroviral medication on a regular basis, she would probably not have fallen ill and been hospitalised.

I told Grace that I would be seeing Mike Hart, the Country CEO and General Manager of East Africa, the next day. I asked her if there was anything I could do or say to help her cause. She wondered why she must continue paying US$11 per month for health insurance, especially now that they will no longer cover her hospital costs. "If I didn't have to pay the money each month to the insurance company, I could use it to buy the antiretroviral medication...I will never get strong unless I get the antiretroviral medication."

Mike Hart was flying in from London. He would be in his office in the early afternoon for an hour or so before going out to visit a few of the Bank's branches. I was told that he would see me.

I came straight to the point. I told Hart that I'd met someone the day before who was HIV positive. She'd been with the Bank 17 years. I asked him if he wanted to meet her. At first, he seemed quite taken aback. And then to his great good credit, he swept aside everything else on the agenda and insisted on meeting her immediately.

Hart explained that like most of the Bank's executives, he is well aware of how acute the HIV/AIDS problem is in Africa. Nevertheless, he'd not yet had an opportunity to meet an employee who was HIV-positive.

I explained that Grace was terrified of losing her job, that she was in a terrible financial position because of her health care costs, and that her health was-- at best--fragile. Nevertheless, he insisted on meeting her and promised to do whatever he could within his power to help.

Grace was trembling with fear. I told her that everything was going to be fine. I reached out and took her right hand firmly in my left hand. I knocked on Hart's door, opened it and entered. Mike Hart rose from behind his desk. He came around his desk to shake Grace's hand. He invited her to sit down and then pulled up a chair for himself. He was facing Grace. The first thing he said was, "I want you to know that I will do whatever I can to help you...But I can't help you unless I understand what you've been through, and what you're going through today."

Simple, pure and direct. I don't think I have ever witnessed a purer or more moving act of compassion and leadership.

They spoke for thirty minutes. They spoke as if there was no one else in the room. Hart would ask a question and Grace would answer. Hart said that the most important issue was for Grace to regain her health. They talked about the Bank's health insurance. Hart pointed out that every insurance company has limits to its coverage. He added that his father had been very ill for a long time and that his coverage had run out. Nevertheless, he told Grace that he was going to look into the Bank's insurance coverage and see if a better or more flexible solution might be found.

Grace explained that she could not afford to purchase the antiretroviral medication. Whatever extra money she had at the end of the month was used to repay the Bank for her last hospital stay. Hart said that he didn't know what the Bank's policies might eventually be, but that he was personally going to erase the debt from her account. Grace was stunned by his generosity.

She didn't quite know how to react. Finally, Hart said that he wanted Grace to keep in touch with him. He wanted to see her on a regular basis and know how she was doing. Again, he felt that the most important issue was for her to regain her health.

And then it was time to leave. They rose from their chairs. Grace offered Hart her hand and thanked him yet again. And then Hart stretched his arms around her and gave Grace a big hug. I thought Grace might break down and cry. She didn't. And then I thought to myself what a good thing it was for him to hug her. He would understand how ill she really was. He would feel that she was just skin and bones. And then I realised that he didn't need any convincing. He'd got the message and he was going to do his best to help her.