The calamity of AIDS
I was staying in a vile hotel in Port Harcourt, in Nigeria’s oil-rich Niger delta. The sheets on my bed were ragged and torn, the breakfast bacon was leathery and lukewarm, and there was a sign on the door warning me not to steal things from the room. This being an oil town, my fellow guests all had something to do with the business. All were involved either in pumping the black stuff or protesting about its environmental impact. Burly drilling engineers from Texas mixed with earnest greens from London in the execrable Chinese restaurant on the ground floor.
Port Harcourt is humid, malarial, and prone to riots. No one comes here for fun. But a risky kind of entertainment was rather obviously available. A crowd of prostitutes dawdled in the lobby, between the Chinese restaurant and the elevators. Any male guest who had finished his glutinous chicken-with-tinned-mixed-vegetables and wanted to go to bed had first to dodge some forceful sales pitches. On my first night in the hotel I was outnumbered by about forty to one. The shyer ladies merely beckoned; the more aggressive ones seized handfuls of sleeve or trouser-leg and tugged. One lady grabbed my wrist, declared that she had fallen in love, and pulled me towards the toilets.
After several embarrassed no thank yous, I reached the elevator. But before I could close the door, one of the largest prostitutes squeezed in too and started to tear at my shirt buttons. Then the power failed, the elevator groaned to a halt between floors, and the lights went out. I’m not sure how long it was before the back-up generator kicked in. But time does not hurry when you are trapped in a steel box with a sex worker who weighs more than you and won’t take no for an answer. Every time I pushed her away, she offered to lower the price. She was down to $5 before I convinced her that it wasn’t a question of money.
“So you’re worried about disease?” she asked. I repeated that I was married and simply not interested in her services. She began to explain various ways in which she could enliven my evening without swapping body fluids. “I can give you a massage,” she said. And then, gesturing between her legs, she added: “You don’t have to touch me here.”
As a man who travels alone in Africa and stays in reasonably expensive hotels, I have been propositioned rather a lot. In bars, ladies with long purple fingernails and brittle perms often sit beside me and smile. In most African cities I visit, hopeful girls wave from under broken streetlights or tap on the windows of my taxis and rental cars. Sometimes they are desperately pushy. A waitress in a hotel in Brazzaville memorized my room number when I signed a bill, knocked on my door at midnight, shoved her foot in to stop me shutting it, and wriggled inside. She then refused to leave until I took her by the shoulders and pushed her gently but firmly outside.
A barbershop I used to visit in Zimbabwe mirrored that country’s decline over the years I’ve reported from it. It was a friendly place with pink walls in a smart part of Harare, the Zimbabwean capital. In 1998, when I first walked in, it was just a barbershop: bustling, thriving, and businesslike. The young women working there were mildly flirtatious, but they never offered to do more than just cut my hair. They did it cheaply and well, so whenever I later found myself in Harare with a fringe flopping into my eyes and an hour to kill, I went back.
Each time I returned, the barbershop had grown emptier and sleazier. The government’s terror campaign against whites and dissidents had driven off all the tourists, and the collapse of Zimbabwean industry had drastically reduced the number of locals who could afford to pay someone else to cut their hair. The lines of customers vanished, and the hairdressers gradually switched from light-hearted flirting to insistent hustling. The last time I went there, in 2001, I was the only customer. Before I even sat down in the barber’s chair, the lady I had asked to cut my hair offered instead to take me upstairs for a shower and a body-rub. When I said no, she asked if I preferred one of the other women working there. Two of her colleagues appeared from nowhere and started pulling my wrists. I left a bigger-than-usual tip for the haircut and never returned.
All these encounters sadden me. When an African woman offers to sleep with me for money, I know I am talking to someone who will probably be dead in a few years. Most African prostitutes contract the human immuno-deficiency virus (HIV), which leads to AIDS. They die emaciated and ravaged by fungal infections, and they take many of their clients with them.
In rich countries, AIDS is no longer a death sentence. Costly drug cocktails can keep HIV-positive patients alive and healthy for a long time. After being bombarded with warnings in the 1980s, most Westerners know how the disease is transmitted and are fairly cautious about swapping body fluids. HIV prevalence is low throughout the developed world, and only a handful of people actually die of it.
In most African countries, by contrast, only tycoons and cabinet ministers can afford AIDS drugs. By 2002, about 17 million Africans had died of AIDS, and 29 million were HIV positive.1 Pause for a moment to ponder it: 46 million Africans either dead or doomed. It’s more than seven times the number of Jews, Gypsies, and homosexuals murdered by Hitler. It’s one and a half times the 30 million Chinese who died of starvation under Mao Zedong.2 It’s three quarters of the death toll during the whole of the Second World War, and by the time AIDS has claimed its last African victim, it may outnumber even that.
In several countries in southern and eastern Africa, a fifth or more of adults carry the virus. That does not mean that a fifth of the population of these countries will die of AIDS. It is worse than that. Almost all those who are now infected will die in the next ten years, but before they die they will infect others. In Botswana, the worst-hit nation, more than a third of adults carry the virus. The president of Botswana, Festus Mogae, lamented in 2001 that unless the epidemic was reversed, his country faced “blank extinction.”3He was not exaggerating.
Nowhere has the AIDS epidemic run its course, so any predictions about its long-term effects are speculative. But even on the most optimistic assumptions, Africa faces an unprecedented catastrophe. Everywhere I travel south of the Sahara, I see signs of the silent havoc wrought by AIDS. I have visited hospitals where virtually every bed was occupied by an AIDS patient, some so thin that their skin sagged and their arms looked like broken broom handles. I have flipped through the obituary columns in dozens of African newspapers: all are filled with photos of young faces: thirty- and forty-year-olds who died “after a long illness.” I have visited schools that lack teachers because of AIDS and companies whose managers have started to limit the number of funerals employees may take time off to attend.
When my wife and I lived in South Africa, our housekeeper’s boyfriend, a long-distance taxi driver, grew thin and died. The doctor wrote “tuberculosis” on the death certificate, which was accurate enough, but probably only part of the story.
Why is this happening? Why has Africa suffered so much more than anywhere else from AIDS? What can be done to curb the epidemic? I’ve spent years pondering these questions. I still don’t know the answers, but I’ve found some clues. I’ve spoken to doctors, to charity workers, and to politicians. I’ve swapped stories with my wife, a former charity worker, who has written a book about AIDS orphans. While researching it, she used to come home from visits to orphanages with her clothes flecked with tears and spit where dozens of lonely children had clung to her.
In 1998, I went to Uganda, where a taxi driver inadvertently helped me frame the question. His name was Charles, and he drove me along the unlit road from Entebbe airport to Kampala, the capital, after dark. Long-horned cattle blundered onto the asphalt, but we could not see them until the headlights bounced off their eyes. Cars coming in the other direction sometimes had no lights at all. But Charles hit the gas pedal and swerved when necessary. He coaxed more speed out of an old Toyota than I would have thought possible. He overtook on blind corners. I looked the other way.
As we drove, he told me his life story. He had lost his mother, his father, two brothers, and their wives to AIDS. Everyone in his family knew how the virus was transmitted and that it was deadly. But they still failed to take precautions. And the thought struck me, as we sped and weaved through the dimly visible traffic. Anyone who wants to curb the devastation that AIDS is wreaking in Africa must answer this: how do you promote safer sex on a continent where no one wears a seat belt?
We Westerners have grown accustomed to caution. We wear crash helmets when we cycle, we expect our governments to ensure that every last molecule of any chemical that even sounds scary is removed from our tap water, and we buy bags of nuts with the words “Warning: contains nuts” on the packet. All this is quite recent. Our great-grandparents did not expect all their children to survive to adulthood. Premature death doubtless upset them as much as it upsets us, but it did not surprise or anger them so much. It was too common for that.
In this respect, Africa resembles Europe at the turn of the twentieth century. Poverty fosters a kind of fatalism. Life is hard when you are poor and death could come at any time. Malarial mosquitoes swarm at night, but you can’t afford mefloquine. You take the cheapest, most crowded minibus to work, which is cheap because it’s old and the brakes are dodgy.
You take things one day at a time and seize passing pleasures when you can.
How the virus spreads
Most scientists think that HIV originated in the rainforests of central Africa in the 1920s or 30s and then eventually spread around the world. Some Africans are insulted by the assertion that AIDS began in Africa and feel that they are somehow being blamed for the disease. They are not. A deadly virus evolved and jumped from apes to humans, perhaps when a woman with a cut on her finger prepared chimp meat for the pot. No one could have foreseen this, and no reasonable person could believe that it was anyone’s fault. The question of exactly when and how HIV first found its way into a human bloodstream is of great scientific interest. But of more immediate concern for anyone interested in keeping the death toll down is the question of how it spreads today.
Unlike in the West, HIV in Africa is contracted mainly through heterosexual sex. Men and women infect each other when they make love without condoms. The virus then travels from town to town along the old colonial highways, in crowded minibuses and lorries. Its staging posts are bus stations and truck stops, where travelers meet locals and the virus finds new hosts.
I visited a truck stop at Beitbridge, on the border between Zimbabwe and South Africa. It was hot and dusty, and there was not much to do. A little kiosk sold cold Cokes and beef jerky, but that was about it. Truck drivers waiting to cross the border parked their eighteen-wheelers on any vacant patch of dirt and opened cans of Castle beer. As dusk fell, they sat in their cabs, watching a parade of young women in tight tops saunter by. When they saw one they liked, they called out to her.
“Sister, come and cook for me,” was the most common come-on. It was meant literally. Cooking was part of the package. Every trucker had a pot, a stove, and a chicken or some fish in a plastic bag. For a few rand, a truck-stop prostitute would cook a tasty stew with whatever ingredients the trucker had on his dashboard. And then they drew the curtains across the windscreen.
“I fuck thirty bitches a month,” boasted John Masara, a twenty-nine-year-old trucker. He slammed his fist into the palm of his left hand to emphasize the point. He was wiry and strong, with a thin gauze of facial hair and enough beer in his bloodstream to loosen his tongue. Fucking was the only entertainment in Beitbridge, he explained. It could take a week to process the paperwork required to move a load over the border. Rumor had it that customs officials owned shares in local hotels. Most truckers shunned hotels, however. It was cheaper to sleep where they parked or to pay a prostitute for a share of her mattress.
Did Masara know about AIDS? Sure, he said, a colleague died of it two days before. He knew how the virus spread, too. “You get it from women.” He knew how to protect himself too, but did he use condoms? “Sometimes,” he said. His friends laughed: “When you’re not drunk.”
He ignored them and said that he “condomized” with most women but not the most beautiful ones. A trucker’s life is dangerous, he explained. He’d been hijacked by men with guns. Any day, he said, he could fall asleep at the wheel and die in a ditch. But the job paid well by local standards, so he had some spare cash. He figured he might as well have some fun while he could.
His relaxed attitude to risk extended to his two wives, whom he said he saw about once a month. They didn’t ask him to use condoms, so he didn’t. “There’s nothing I can do about it.” He shrugged. “I’m a trucker.”
Masara’s wives probably didn’t know how much danger they were in. Most of the prostitutes he slept with, by contrast, understood the risks but carried on as if they didn’t.
Chipo Muchero, for example, who sold sex on the Zimbabwean side of the border at Beitbridge, insisted that “if a client won’t use a condom, then I refuse sex.” But she was lying.
Her black hair was bleached yellow at the front. Her denim dungarees were cut off above the knee, to expose bruised calves. She was suspicious of questions but had nothing better to do than answer them. Business was slow: there were too many women in the same line of work in the crowded slum where she lived and not enough clients to keep them busy.
Muchero hung out with half a dozen other women of varying ages outside a dark, one-roomed house with mud-brick walls. There was no sign outside to indicate that it was a makeshift brothel. It was no different from hundreds of neighboring homes: mostly mud and wood, occasionally reinforced or waterproofed with sheets of corrugated iron or black plastic. Dirty water ran past in an open ditch. Children dashed around playfully shrieking, while their mothers built fires or scrubbed clothes.
Muchero and her friends all did other kinds of work, too. They fetched water and firewood, sewed and cooked, and tended small patches of corn. But no one paid them for any of this. To earn cash, they brought men home. Inside the house, blankets hanging from the ceiling subdivided the room and created a bit of privacy.
After a while, Muchero admitted: “OK, I’ll have sex with any man – trucker, tourist, or local guy – with or without a condom. I need the money. I don’t have a job or education. I have no other option.”4
If she had a passport, she said, she would cross into South Africa and trade things other than her body. She knew others who had done this. South African shops are cheaper and better-stocked than those in Zimbabwe, so there is money to be made buying toasters and televisions on the South African side and bringing them home to sell. One store in Messina, the nearest sizeable South African town, had a big red sign outside proclaiming that “Zimbabweans and hawkers are welcome for one-stop shopping.”
But Muchero could not afford a passport. To get by, she entertained about four clients a week. The price was fixed by haggling; she usually made between one and two dollars per trick. Eventually, her job was bound to kill her. But in the short term she could think of no other way to support herself.
How AIDS keeps Africa poor
After the Black Death wiped out a third of the population of medieval Europe, many of the survivors were better off. Because so many died there was a sudden labor shortage, and landowners were forced to pay their workers better.
Africans who survive AIDS will not be so lucky. AIDS takes longer to kill than the plague did, so the cost of caring for the sick will be much greater. Modern governments, unlike medieval ones, tax the healthy to help look after the ailing, so the burden of AIDS will fall on everyone. And because AIDS is sexually transmitted, it tends to hit people in their most productive years.
AIDS is making Africans poorer. But since the epidemic has not yet run its course anywhere, any prediction as to how much poorer it will make them involves a lot of guesswork. For what it’s worth, researchers at ING Baring, a bank, forecast that the South African economy will be 17 percent smaller in 2010 than it would have been without the virus. They could be wrong. But there is no doubt that AIDS will make a lot of things worse.
Africa’s already painful skills shortage will grow more acute. Skilled workers who die will be hard to replace, not least because so many teachers are dying too. Zambia is suffering power shortages because so many engineers have succumbed. Farmers in Zimbabwe are finding it hard to irrigate their fields because the brass fittings on their water pipes have been stolen for coffin handles. All over Africa, AIDS is making employees sicker and therefore more expensive and less productive. Costly and unproductive employees tend to get sacked.
At a national level, the effect of AIDS is felt gradually. But at a household level, the impact is sudden and catastrophic. When a breadwinner falls ill, his (or her) family is impoverished twice over. Their main source of income vanishes, and they must somehow find extra money for medicine. Daughters drop out of school to help nurse their ailing fathers. Because husbands infect wives and wives infect babies, AIDS often strikes several times in the same family.
A study in urban Côte d’Ivoire found that households afflicted by AIDS subsequently spent only half as much on education. Family members ate two-fifths less and were forced to spend four times as much on health care. Another survey in Tanzania found that a woman whose husband was sick with AIDS spent 60 percent less time growing food than before. And in Zimbabwe the disease so weakened peasant farmers that the ones tilling communal land produced half as much in 1998 as they had five years previously.
Orphans of the virus
I went to Ndola, in the copper-mining region of northern Zambia, where I had heard that the virus was wreaking particular havoc. The local cemeteries bore grim witness to the truth of this rumor. It wasn’t just that they were so huge or that so many of the headstones were new. What struck me was how unkempt the places were. There was a shortage of survivors, I was told, with the energy to tend the graves. Those whom the virus missed were often too busy battling hunger to waste time and burn calories hacking back the long grass that had swallowed their relatives’ tombs. Many graves were lost in the undergrowth. And some had been dug up: local thieves were so desperate, a local charity worker told me, that they stripped fresh corpses of the smart suits in which they were buried.
AIDS is wiping out whole families: the Zambian health ministry estimated that half of Zambia’s population would eventually die of it. Those who die are mostly breadwinners or mothers. Estimates of the proportion of Zambian children who have lost one or both parents (usually, but not always, from AIDS) range from 13 percent to 50 percent.5 If the difference between these two numbers seems absurdly large, remember that accurate statistics are rare in countries as poor as Zambia. Personally, I don’t believe that the higher figure can be true. But even at the lowest estimate Zambian children are a dozen times more likely to be orphaned than children in rich countries.
It is not only children who are hit. Elderly Africans usually expect their adult children to look after them in their twilight years. But because AIDS is causing many middle-aged people to die before their parents, the elderly are being “orphaned” at an alarming rate. Not only do they lose their main means of support, but they suddenly find themselves caring for their orphaned grandchildren as well.
I met one such elderly orphan in a “compound” (shanty town) near Ndola. Faides Zulu, a small and slender grandmother with gentle eyes, was old enough to have no idea when she was born. We spoke, through an interpreter, sitting on a rush mat on a concrete floor in a schoolhouse, where she came about once a month to receive a bag of corn from a local Catholic charity. Both her daughter and her daughter’s husband died in the same year “after being sick for a long time,” leaving her to look after five small children.
Faides Zulu’s “second motherhood” was not easy, she said. She grew vegetables in her backyard and then walked several miles on frail legs to sell them. One child was often ill, with bloody diarrhea, fever, and headaches. She preferred not to talk about the likelihood that this child had contracted HIV from his mother, either during birth or while breastfeeding.
Zulu fretted about the future. “I am old,” she said. “In ten years’ time I will not be able to work in my garden. What will happen to my children then?” Probably, she guessed, her eldest granddaughter would land the responsibility of looking after her younger siblings.
In 2002, there were an estimated 11 million AIDS orphans living in Africa. Extended families have adapted heroically to the crisis. In Zambia, one study, conducted in the parts of the country worst hit by AIDS, found that 72 percent of households had taken in one or more orphans.6 The national average is probably lower than this, but there is no doubt that such generosity is common.
Throughout Africa, families have opened their arms and homes to orphaned siblings and nephews. No matter how poor they are, they have welcomed them without hesitation, fuss, or a hint of resentment. There are millions of Faides Zulus, most of whom show a warm selflessness that leaves me stunned with admiration.
AIDS has put these families under a huge strain, of course. Extra mouths mean less food to go around, so many fostered children are made to work for their keep. The unluckiest can slip through the family safety net entirely. For example, if a mother dies of AIDS, her relatives sometimes wrongly assume that her baby too is doomed and so don’t waste scarce food delaying the inevitable.7 For the most part, however, Africans have lavished their orphaned kin with love and pumpkin-leaf stew. Not even AIDS can break the African extended family.
Why AIDS is hard to curb
The best hope for halting AIDS would be a cheap vaccine. Scientists are trying to find one, but it could take years. HIV mutates rapidly, so it is hard to teach the body’s immune system to recognize and attack it. In the short term, the only way to curb the epidemic in Africa is to persuade people to shun risky sex. This is also hard, for several reasons.
Sex is fun. And many people feel that condoms make it less so. Zimbabweans ask: “Would you eat a sweet with the wrapper on?”
Talking about sex is often taboo. Many traditional parents think it shameful to discuss the subject with their children. Some conspiracy theorists even argue that the whole hoo-ha about AIDS is a bizarre plot to make blacks appear immoral. When my wife’s book on AIDS orphans was published, a South African reviewer accused her of trying “to advance a racist ideology that portrays African people as promiscuous and reckless” simply because she repeated the conventional view that HIV originated in Africa.8
Myths abound. Some young African women believe that without regular infusions of sperm, they will not grow up to be beautiful. Ugandan men have been known to use this myth to seduce schoolgirls. In much of southern Africa, HIV-infected men believe that they can cleanse themselves of the virus by passing it on to a virgin. This is an old myth. Nineteenth-century Brazilian slave-owners thought they could cure themselves of syphilis in the same way. The result is the same in Africa now as it was on Amazonian rubber plantations a century and a half ago.
Poverty. Those who cannot afford television find other ways of passing the evening. Poor people often cannot afford antibiotics to treat other sexually transmitted diseases (STDs). STDs can open sores on the genitals, which provide easy openings for HIV to enter a new host.
Migration. When people are mobile, the virus spreads. Migrant traders and bricklayers flock to South Africa, where wages are much higher than in neighboring countries. Gold miners spend eleven months of the year apart from their families, often living in single-sex dormitories surrounded by prostitutes. Living with a one in forty chance of being killed in a rockfall, they are inured to risk. When they go home for Christmas, they often infect their wives.
War. Refugees spread HIV as they flee. Soldiers, with their regular wages and disdain for risk, are more likely to be infected than civilians. They are also able, in the chaos of battle, to rape with impunity. A friend and colleague of mine, James Astill, theEconomist’s former Nairobi correspondent, spent time with the Mai-Mai, a ragged militia band notorious for gang-raping peasant women in eastern Congo. They offered him a chance to ingest a charm they said would make him invulnerable: a paste made from the severed penises of their enemies, the Rwandan soldiers who had invaded Congo. The spell worked, they said, if you opened a cut in your arm and rubbed in the paste. They all used the same rusty knife. James said thanks but no thanks.
Sexism. Many African women find it hard to ask their partners to use condoms. In one survey in Zambia, less than a quarter of women believed they had the right to refuse sex with their husbands even if they knew he was unfaithful and HIV-positive. And only one in ten thought she could ask him to use a condom in this situation. Women who try to insist on condom use risk being punched. In two districts in Uganda, 41 percent of men admitted to researchers that they beat their partners. Another study found that sexual violence was “widespread” in South African schools.9 Forced sex is an unusually effective means of HIV transmission because the victim usually bleeds.
Alcohol. African beers are, by and large, delicious. Drunken lovers are less likely to remember to use condoms. A survey of women in an area frequented by sex workers in Carletonville, a mining town in South Africa, found that 65 percent of those who drank were HIV-positive, compared with only 30 percent of non-drinkers.
Finally, there is the question of foreskins. Several studies suggest that African men who are circumcised before puberty are less likely to contract HIV. Even allowing for cultural differences between groups that snip and groups that don’t, circumcision appears to offer limited protection. Possibly this is because the tip of the penis grows tougher if not cushioned by a foreskin. Unfortunately, the discovery that circumcision makes sex safer has led some people to believe that it makes sex safe and so they neglect to use condoms.
None of these problems is unique to Africa. But nowhere else has them all in such abundance. Of all the factors driving the epidemic, promiscuity is the hardest to discuss without upsetting people. Sexual mores clearly differ between cultures. Premarital sex carries less of a social stigma in Holland or Japan than in, say, Saudi Arabia. But it is hard to determine how promiscuous societies are, because people lie about sex. Ask a young British man how many women he has slept with, and he may exaggerate the number to make himself seem more virile. Or, if he is religious, he may downplay it.
We don’t know how much sex Africans have, or how many partners they have it with. But a couple of generalizations are possible. First, many sub-Saharan societies are relatively permissive. Polygamy is quite common. Sex may not be discussed openly, but many men flaunt mistresses, and unmarried urban women do not seem embarrassed when a boyfriend stays the night.
What may be as important as the number of partners is what is called the “pattern of sexual networking.” Consider the way AIDS spreads in Thailand. Thai women are expected to be virgins when they marry, but men can fool around without being thought immoral. Extramarital sex usually means a trip to a brothel. If a Thai man contracts HIV, it will probably be from a prostitute. He may then pass the virus on to his wife, who may infect her unborn child. The family is destroyed. But the chain usually stops there.
In Africa, the pattern is often different. A married man may have sex with prostitutes, but he may also have casual affairs with teenage girls. Girls who contract HIV from a “sugar daddy” often survive long enough to get married and pass the virus on to their husbands. Those husbands may then have affairs with younger women. And so on. Sex between people of different generations helps keep the virus circulating.
In eastern and southern Africa, HIV prevalence is far higher among teenage girls than boys. The only plausible explanation is that young girls are having sex with older men who have been sexually active for long enough to contract the virus.10 Anecdotal evidence is plentiful, too. Anyone standing outside a high-school gate in Kenya or Zambia will sooner or later see girls get into cars with middle-aged men who are not their fathers. These girls then usually go on to marry men of approximately their own age.
How to fight it
There is hope. Two African countries – Uganda and Senegal – have shown that AIDS can be curbed. Uganda’s example is especially heartening because it shows what can be done with almost no money.
Uganda is poor by any standards. When Yoweri Museveni seized power in 1986, the country was one of the poorest and most violent in the world. In the 1970s and 80s, under the tyrants Milton Obote and Idi Amin, perhaps 800,000 Ugandans were shot or bludgeoned to death or starved when soldiers stole their harvests. Average annual income in Uganda was a meagre $150 or so. Half of the population was illiterate. Years of chaos and civil war had allowed HIV to spread unchecked, although no one knew this at the time because the doctors who might have tested people had mostly fled the country.
President Museveni has his faults, but he quickly recognized the threat that AIDS posed. In 1984, he recalls, while listening to the BBC he heard an Italian professor talking about the situation in Zambia. He explained that HIV could be spread through heterosexual as well as homosexual intercourse. “I thought this was very dangerous, given the habits of our people – it would finish them,” Museveni told the Times. Shortly afterward, he sent sixty of his soldiers to train in Cuba, where the government tested them for HIV. Museveni was shocked to discover that eighteen of them were infected.11
He acted swiftly, forcing every government department to draw up a plan suggesting what it could do to tackle AIDS. The budget was tiny, but they coped. Accurate surveys of sexual behavior were conducted for only $20,000–30,000 each. Posters discouraging risky sex were erected by busy roads. A rise in literacy, from 51 percent in 1980 to 65 percent in 1998, allowed more Ugandans to read them.12
To fill the gaps that the state could not, non-governmental organizations (NGOs) were given free rein to do whatever it took to educate people about HIV. Scores of charities, many foreign-financed, took up the challenge. I visited a few, including the Straight Talk Foundation, which publishes newsletters that teach adolescents and pre-teens about sex in a straightforward, unpreachy way. Rather than seeking to scold or scare, they probe the complexities of puberty, relationships, and sex.
Talking about relationships is often more important than talking about the mechanics of how HIV is transmitted. For many young people, the problem is not that they are ignorant about AIDS but that they are unsure how to deal with romantic situations. So Straight Talk’s volunteers do not merely issue warnings; they run romantic role-playing sessions in Ugandan schools. These help girls learn how to insist on condoms, for example, or how to persuade their boyfriends that they are not yet ready for sex. Convincing teenage boys that remaining a virgin is cool has proven more difficult. One reason, according to Cathy Watson, the foundation’s director, is the popularity of pirated Western porn videos, which some viewers think reflect the way rich and sophisticated people behave.
Straight Talk’s newsletters, handed out free in schools, cover everything from nocturnal emissions to what to do if raped. Visiting AIDS workers from Zimbabwe and South Africa asked Watson how she won government permission to distribute such explicit material. They were astonished to hear that she had not felt the need to ask.
The climate of free debate has led young Ugandans to delay losing their virginity, to have fewer partners, and to use more condoms. Among fifteen-year-old girls, the proportion who said they had never had sex rose from 20 percent in 1989 to 50 percent in 1995. Between 1994 and 1997, the proportion of teenage girls who reported ever having used a condom tripled.
And the epidemic was rolled back. Between 1992 and 2002, HIV prevalence among women attending urban antenatal clinics fell from almost 30 percent to about 5 percent.13
If Uganda shows how a poor country can roll back an epidemic that is already raging, Senegal shows how to stop it taking off in the first place. West of the Sahara, this mainly Muslim country is fortunate to be several thousand miles from HIV’s origin in central Africa. In the mid-1980s, when other parts of the continent were already blighted, Senegal was still relatively HIV-free. In concert with NGOs and the media, the government set up a national AIDS-control program to keep it that way.
In Senegal’s brothels, which had been regulated since the 1970s, condom use was firmly encouraged. The country’s blood supply was screened early and effectively. Vigorous education resulted in 95 percent of Senegalese adults knowing how to avoid the virus. Condom sales jumped from 800,000 in 1988 to 7 million in 1997. Senegalese levels of infection have remained stable and low for a decade – at under 2 percent.
How to dither and die
Other governments have been less alert. South Africa, for example, has resources and skills that Uganda and Senegal can only marvel at. But AIDS-prevention efforts in South Africa have been, to put it kindly, confused.
The government had plenty of warning. AIDS came late to South Africa. In 1990, it was a relatively small problem. Fewer than 1 percent of South African women in antenatal clinics tested positive for HIV that year. The African National Congress had ample opportunity to observe the epidemic devastating South Africa’s northern neighbors. But perhaps because negotiating an end to apartheid was such an all-consuming task, they did not pay it much attention.
During its first five years in government, 1994–9, the party did practically nothing. Nelson Mandela, South Africa’s first black president, rarely mentioned the disease. When I arrived in South Africa in 1998, I was amazed to see no anti-AIDS posters at all. In my first year in the country the only two I noticed were both in a small office used by the United Nations anti-AIDS program in Pretoria. The only senior member of Mandela’s government who tried to do much about AIDS was the health minister, Nkosazana Dlamini-Zuma. Her contribution was to sponsor a costly flop of an anti-AIDS musical, to promote a toxic “cure” based on an industrial solvent, and to purge South Africa’s drug-control agency when its members objected.
By 2002, HIV prevalence had risen fifteenfold, making South Africa the country with the most infected people anywhere in the world. Roughly 4.5 million South Africans carried the virus.14 By way of comparison, this is more than 200 times the number of people who died in political violence during the turbulent decade before liberation.
Many people hoped that Thabo Mbeki, who succeeded Nelson Mandela as president in 1999, would take the catastrophe more seriously. He did, but not in the way anyone expected. After long nights researching the subject on the Internet, he began to question whether HIV really caused AIDS. He appointed a panel of experts to look into the matter, including some American AIDS “dissidents” (who denied that HIV caused AIDS) and excluding anyone from African countries that had actually succeeded in tackling the epidemic. His health minister, Manto Tshabalala-Msimang, circulated chapters from a book claiming that HIV was concocted by a secret organization called the Illuminati as part of a conspiracy to wipe out homosexuals, blacks, and Hispanics. All this nonsense baffled ordinary South Africans. Some thought that their president was telling them that AIDS didn’t exist and concluded that it was therefore OK not to wear condoms.
Despite all the strange goings-on in the presidential mansion, many young South Africans seem to have realized that unprotected sex is risky. The media have treated the issue far more responsibly than the government has. NGOs have paid for a lot of gaudy posters on city billboards and pamphlets suggesting how to have fun without penetration. The main targets of these warnings are teenagers. Those who are not yet having sex are rarely infected. If campaigners can catch them while they are still virgins and persuade them either to stay that way or to use condoms, a generation could be saved. It might yet be. A survey of young women in 1998 found that only 16 percent said they had used a condom the last time they had sex with someone they weren’t married to. By 2000, another survey found that a more encouraging 55 percent of young South Africans said they always used condoms. One hopes most were telling the truth.
Thabo Mbeki attracted so much criticism for his attitude to AIDS that he eventually said he would “withdraw” from the debate. His government’s policies then started to improve. In November 2003, the South African government unveiled a serious, well-funded, and long-term plan for treating its sick citizens with the anti-retroviral drugs that have worked so well in rich countries – which would make no sense if HIV did not cause AIDS. Such drugs are not a solution; they suppress the disease, but they do not cure it. But if the plan is competently implemented, they should keep millions of South Africans alive long enough to raise their children to adulthood. Other African countries still find it hard to afford such drugs, but the prices are falling fast, and foreign donors are increasingly willing to pay for them.
A speck of hope
Looking at the carnage AIDS has wrought in Africa, it is easy to despair. Some Africans do. Chenjerai Hove, a Zimbabwean novelist, put it like this: “Since our women dress to kill, we are all going to die.”15 But if the sexual urge is basic, so is the will to live. If enough Africans wake up to the fact that unprotected sex is Russian roulette, Hove could yet be proved wrong.