As a public health worker in East Africa, the professional objective is simple: Improve the health and well-being of the population. The tools with which to do this are clear: health education, sustainable delivery of effective prevention and treatment interventions, and capacity-building and strengthening of health systems. The professional objective is simple—isn’t it?

In the concrete, austere HIV/AIDS building in the middle of a rural Tanzanian community, men and women sit patiently. They wait to meet with the counselors, to discuss their health and sexual histories, to receive an HIV test, to hear what their future does or doesn’t hold. Kai is a slight woman in her late 20s. The bright pinks, blues, and yellows of her kanga are faded, much like the woman wrapped tightly inside. Her face looks worn and tired. She has been referred here as part of a new opt-out program that tests everyone who comes to the health center, no matter the reason for their visit. I begin my explanation of what HIV is, how the test is administered, and what the results mean. She sits in silence with an empty expression before asking, “What is the point of this test, Miss?” I begin my explanation once more, but she puts her hand up and says, “No, I mean, what is the point? It is only proof of what I already know. My husband does not love me. I know what he is doing when he doesn’t come home. … But how can I stop this from happening?” She shakes her head as if to shake out a bad thought or a disturbing memory. I point out that if she does have HIV, this would be an opportunity for her to get the proper care, to start treatment if needed, and to slow the disease’s progression. If she tests negative, she could continue measures to prevent its spread. In my head, I can hear the words leave my mouth, and I feel embarrassed by how simple, how trite this answer seems. She appears like she is only slightly amused by my foreign naïveté before saying gently, “And what do you think my husband would do to me if he found me taking your medicine? He would blame me for bringing this disease into his home, even though we both know it came from him. Prevention? Do you think I can ask my husband to wear condoms? Do you think I can stop him from doing what he wants with me? No. It is better to let it be. What God wants to happen will happen.”

As I watch the door close behind her, I wonder if we are misleading our patients, especially the women. Is knowledge really power for someone who feels so powerless? I have heard Kai’s story more times than I have not. Among those who do get tested, after hearing their results whether positive or negative, the response is often the same: “What now?” Though I give my standard response about care-seeking if they are positive or prevention measures if negative, I know that they are asking something deeper than that, something to which I have no answer. They are asking about a reality whose surface I can only begin to scratch, about a life that I cannot contemplate. I thought I was here to inform people of what their options were; but are these really options at all?

A few months later, Kai reappears at the clinic. This time two of her small children hang off of her body, which now has a telling belly swelling underneath her clothing. Today, she agrees to be tested. When I get the results back, I feel my heart sink. Yet, as I prepare myself to break the news, she looks like she already knows. She says to me simply, “I never had a chance, but this one does.” She pats her belly. I wonder what it is to feel such hopelessness for one’s own life but such hope for another’s, to give up on one’s own future and to instead transfer all dreams to someone else’s.

After that, I see Kai regularly in the clinic. One day, she enters with a black eye and bruises on her arm. She tells me sadly that her husband discovered her ARVs and recounts how he beat her and left her to find a “clean wife.” Embarrassed by the tears that are burning my eyes, I look away. Finally, she breaks the silence by saying, “I thought I was saving this baby, but instead, I have doomed us both.”

Yet, Kai continues to come to the clinic to receive her ARVs until her delivery. Her baby arrives with little celebration. There is no father bedside to cut the cord, and rather than being presented to the mother, this baby is whisked away for weighing, measuring, and her first dose of HIV prophylaxis. After she is discharged from the health center, I help Kai gather her belongings and watch her begin her journey home on foot. She smiles at me warmly and thanks me for helping to save her baby. I feel uncertain that I have done anything at all. I should feel happy—I got an HIV-positive woman on life-saving therapy, and we successfully prevented her from transferring the virus to her newborn. I did my job—didn’t I? As I watch her walk down the dusty road, she stops suddenly and waves. I hear her voice in the distance: “Kwa heri, dada.” Goodbye, sister.

As a public health professional, the professional objective is simple: Improve the health and well-being of the population. But how do we do that when improving health and improving well-being seem to be at odds? Before coming to Africa, I believed the most difficult choices in health were those that straddled the line between life and death. But here, in rural Africa, the most difficult choices in health are those that straddle the line between life and living.