My friend Marion died when she was 28. She lived in Harare, the capital of Zimbabwe. She was slim, attractive, cheerful and competent, the epitome of the new Africa on which people like South Africa’s President Thabo Mbeki and Nigeria’s Olusajun Obasango pin their hopes for their devastated continent. She studied hard, had a wall filled with diplomas and certificates and became the administrator of a regional non-governmental organization.
One day at tea she told us she wanted to have a baby, that an African woman’s life was incomplete without children. So she got pregnant quite deliberately. And just as inexorably, she got the virus we call HIV.
Almost immediately, Marion started getting thin, having terrible headaches, sinus problems, and a host of “minor ailments.” In the African way of 1998, we never talked about AIDS, it was always something else. Her slim figure became stick-like except for the increasingly visible tummy of her first baby. Then she began missing work, too exhausted to get up. Finally she came to the office no more.
The last time I saw Marion was in a print shop: noisy, dirty and hot.
“Hi Marion, how are you?”
“I’m fine, just a little headache but the doctor’s giving me Panadol (pain killers) and I should be okay soon.”
She had to sit on a grubby chair to talk to me. It was just the normal chat about nothing in particular but I sensed something must be coming.
“Can I ask you a favour? I want to bring my sister from Cape Town right away and I don’t have enough money, I’ll pay you back.”
“Sure, Marion, that’s great. Maybe she will be able to help you when the baby comes.”
“I’m okay. Can I call my baby Matthew after your son?”
“That’s an honour, Marion.”
She left slowly, holding onto a friend’s arm, looking twice her age, to cash the cheque. It was a Friday. The baby was born on Sunday and Marion died. The baby, Matthew, survived and lives today with one of Marion’s sisters.
Another story illustrates, and makes human, some of the studies and statistics that came out of the recent Barcelona AIDS conference, reminding us that the stunning vulnerability of women to this 21-year-old pandemic in sub-Saharan Africa (and especially in southern Africa) is not just physiological but also cultural.
Anastasia Muringayi is 44. She lives in Chishawasha, about 40 km from Harare, and she has seen eight members of her family die since 1993.
There is no sugar there any more, so Anastasia cannot use the tough plastic bags it comes in to protect her hands from the feces, urine, blood and vomit of her bedridden family and neighbours. She tried the flimsy plastic that comes around bread loaves but now Zimbabwe has no bread a widow can afford.
But Anasatasia is a tough, strong woman — African women, generally, are the steel backbone of a continent ruined by men. She has joined a Roman Catholic mission’s AIDS care group. When the hygiene packs came from the AIDS program there were only two pairs of disposable gloves; each can be used only once. It seems that for the volunteer caregivers, exposure to bodily fluids contaminated by HIV is minor compared with the desperate food shortages: the staple maize meal and cooking oil ran out two months ago.
Next door to Mrs. Muringayi’s brick and thatched hut lie Roger and Everine, both sick, but until the food ran out, able to care for themselves.
Nearly six million Zimbabweans — half the population — need emergency food rations as people do in nearby Malawi, Zambia, Mozambique and most other nations of the Southern African Development Community (SADC). Thirty-four percent of Zimbabweans between 15 and 49 are infected with the virus that causes AIDS.
AIDS and famine were made for each other. For the hungry and sick it no longer matters whether the famine was caused by President Robert Mugabe’s mad and corrupt land-reform policies or this year’s drought. Malnutrition lowers already fragile immune systems.
The virus ravages the weakened body, accelerated as the hungry sell themselves for food. The breadwinners die, their infant orphans and elderly relatives face starvation.
Halfway through her family’s death, starting with her husband in 1993, Mrs. Muringayi learned that if she was going to be the sole care-giver she must practise careful hygiene. She has been left with two orphans and three of her own children. She has had to slaughter her eight cattle, her well has dried up and her small garden of yellowing tomatoes and spinach is her sole source of income. When government aid workers occasionally drop off a few bags of maize meal, it is never more than half enough.
Despite her strength and the support from the church, Anastasia suffers acute depression from time to time, especially as people die.
“I get afraid. I am always asking, is it me next to die?”
But her counseling and home-based care pulls her through and she goes on with a kind, endless cheerfulness. But the load is “too heavy. There is almost no one else left now. However, there is no new sickness that we know of.” Not yet, but Anastasia knows she is HIV-positive and is beginning to show the lesions and rashes so common among people who are infected. She is still strong but she gets tired more easily.
There are 13 million orphans left either in the seething urban slums of Africa’s cities with nothing; or attempting to live in child-headed households in adult-empty villages, with nothing.
Their biggest hope, education, is lost. UN statistics revealed that last year alone, a million students lost their teachers to AIDS. And no one, especially ministers of education, knows how they will replace them or where they will find trained substitutes for the many teachers who are off work sick for long periods.
The government of Mozambique recently said that 17 percent of its teachers will die of AIDS before the middle of this decade.
Better and more universal education is critical to Africa’s development. The hopes of the New Partnership for African Development (NEPAD), to which Prime Minister Jean Chrétien has devoted so much time and energy, was given short shrift compared to George W. Bush’s war on terrorism at the G8 summit last summer at Kananaskis, Alta. One of its key goals was to have every child who is eligible enter school, reinforcing the unfulfilled principle in Africa of gender equality.
But, in the middle of the NEPAD document, almost ignored, is the following: “One of the major impediments facing African development efforts is the widespread incidence of communicable diseases, in particular HIV/AIDS, tuberculosis and malaria. Unless these epidemics are brought under control, any real gains in human development will remain an impossible hope.”
AIDS statistics are mind-numbing. They have been since the first virus caught our attention more than two decades ago. And they are going to get much, much worse.
In the 25 countries of sub-Saharan Africa where the prevalence rate of HIV is above five percent — considered to be the dangerous takeoff point for the pandemic — there will likely be negative economic growth, rather than the positive seven percent envisaged by NEPAD.
Until recently, predictions that HIV/AIDS infections were leveling off put the seemingly intractable disease on the back burner. After all, Canada’s AIDS statistics have declined for years. AIDS is not even listed among the top-10 killer diseases. The rest of the West is much the same.
But at least 68 million people will die of AIDS in the next two decades in the world’s 45 hardest-hit countries. This is five times the number who have died in the previous two decades. The vast majority of these will be in Africa, although reports of major outbreaks in the Indian sub-continent, former Soviet Union and China are ominous signs of a global catastrophe.
“It’s now clear to me that we’re only at the beginning of the AIDS pandemic in historic terms,” says Peter Piot, executive director of the UN’s HIV/AIDS program.
“Contrary to expectations that the HIV epidemic would reach some natural saturation level, we are not seeing any leveling off of infections.”
And, of course, in this age of rich and poor, the vast majority of infected people live in the poorest nations, unable to receive any of the medications that could prolong their lives.
In 1989, predictions of 10 million infections, mostly in Africa, were dismissed by the medical AIDS establishment as alarmist. Seven years later, experts predicted 40 million. Now there seems little that will stop the number from reaching 100 million.
Piot takes a new tack in allocating blame for these appalling figures for a clearly insidious illness that has spread far beyond the initial high-risk groups (gay men, dirty needle-users and hemophiliacs).
This disease, like its related illness, tuberculosis, is a disease of poverty. Political leaders, including those in hard-hit African countries and in those wealthy, sparsely affected countries like Canada and the U.S., must shoulder the blame, says Piot. “One of the main reasons we have such a pandemic — the worst in the history of the world — is a failure of leadership. We’ve lost precious time and that waste of time has led to millions of deaths.”
Kananaskis was a prime example. The G8 leaders, chaired by Chrétien, and attended by Bush and UK Prime Minister Tony Blair, spoke movingly of Africa’s HIV/AIDS plight, but they did not make any firm commitments to act.
The statistics read like a death warrant for 800 million Africans:
- 28 million sub-Saharan Africans living with HIV/AIDS, including three million children;
- more than half the infected adults are women (women and girls are two to three times more likely to contract HIV than men);
- in 2001 alone there were 3.4 million new infections and more than two million deaths;
- the vast majority are in the developing world, especially southern Africa where deaths will outstrip births by 2010, creating an accelerating catastrophe;
- Botswana, with 39 percent of its population infected is “faced with extinction,” says Dr. Banu Khan, co-ordinator of the country’s AIDS agency. Life expectancy in the huge but sparsely populated cattle- and diamond-rich democracy will drop to just 27 years;
- Zimbabwe, at 37 percent, is the second-highest infected country in the world, per capita, after Botswana and just ahead of Zambia. Each week more than 3,000 people die of AIDS in a population of under 12 million;
- Mozambique, with poor statistical collection due to years of poverty and civil war, says life expectancy is now under 30;
- South Africa, with its bigger population, remains the AIDS capital of the world with five million infected, followed by India (4 million) and Nigeria (3.5 million).
- Without AIDS, the average life expectancy in southern Africa today, despite its high rates of poverty, would be around 70 years.
- And, among those many millions of infected people, all equal in the sight of God, the brutal fact remains that only 730,000 of them, less than two percent, last year got the drug cocktails that can dramatically slow the onset of symptoms. In all, 2.2 million Africans died of AIDS last year. In the West 25,000 died.
- “We estimate that less than four percent of the six million people who could benefit from such treatment are actually getting it today,” Piot says.
This is despite vast reductions in the cost of these expensive cocktails — up to 30 drugs daily; some require refrigeration while others must be taken at precise times with first-rate clinical backup which few African or developing countries can afford. Generic pharmaceutical manufacturers in Brazil, India and Thailand have beaten off the more avaricious western drug companies to provide treatment at about US$1-a-day compared with the US$20,000 a year it costs to take brand-name drugs.
The majority of people in southern Africa, must live on US$1-a-day, leaving nothing for AIDS medicines.
Even more frightening, the World Health Organization (WHO) recently did a survey that showed the majority of young people in the world have no idea how HIV/AIDS is transmitted or how to protect themselves from the disease.
There is a small church-supported community centre in Windhoek, Namibia, where people living with AIDS try to avoid the terrible stigma attached to the disease and are able to find a support network. They may have a meal and try to earn some money through an income-generating project. (Most African employers will not have an AIDS-infected employee around. Churches, community organizations, NGOs and society at large avoid people with the disease.)
In Windhoek, the income-generating project involved making tiny papier maché coffins for infants. The workers said with a mixture of pride and anguish that they couldn’t keep up with the demand.
Death in Africa is vastly different from the West. It is a rite of passage, a family ritual with layers of spiritual meaning and a depth of respect and honour. It is the main gathering of the wider family and an occasion for feasting, speech-making, singing, dancing and wailing. The whole community is included. No expense is spared.
Today, with economic collapse and death at every turn, the enormously spiritual and cultural passage is fraying at the edges. Poor people cannot afford funerals, bodies are left in morgues, unclaimed, to be buried in unmarked mass graves. Attending several funerals a week destroys the meaning of death and the role of ancestors.
The culture crumbles. Witchcraft begins to thrive and older women are killed for casting an evil eye on a man who has become sick with HIV. Men seek out young women who are virgins, believing they will be purified and their blood purged of the disease.
Herbal and traditional cures are rampant as desperate people seek relief. But little works.
Most African leaders, working in the “strong man” mode, have been reluctant to speak out about AIDS and recognize its seriousness. Presidents such as Robert Mugabe of Zimbabwe, Sam Nujoma of Namibia, Daniel arap Moi of Kenya, for example have spent years of their long terms in office in denial, yet their countries are among the worst hit.
Others such as Thabo Mbeki in South Africa have made controversial statements at odds with most scientific opinion, often further confusing people who are already uninformed and in denial.
In cases where leaders have taken a public stance against discrimination of people with HIV/AIDS, and have publicly recognized the severity of the pandemic and the need for education and support, dramatic turnarounds have occurred.
President Yoweri Museveni of Uganda, and the former presidents of South Africa and Zambia (Nelson Mandela and Kenneth Kaunda) have taken outspoken and principled stands in solidarity with their people who live with AIDS, openly acknowledging the cause of death of their offspring and relatives instead of the usual words “. . . died after a short illness . . .” that appear in the packed obituary pages of Africa’s newspapers.
Uganda, which once held the dubious title of the most infected country in Africa, saw a dramatic change once Museveni began to speak about HIV/AIDS daily. While even today whole villages are depopulated and the disease is far from ended, there is a new optimism.
Churches in Africa, with some notable exceptions, have been largely silent, some even denying the last rites to those dying of HIV/AIDS. A meeting this summer in Nairobi, Kenya, of 120 church leaders from 30 African countries acknowledged that “they had not fully unleashed the rich assets for action” and that they “had been reluctant to speak openly about HIV/AIDS.”
They agreed that they had “been strangely muted” given the scale of the pandemic and acknowledged that certain faiths and denominations have problems around the use of condoms and are also struggling with the leadership roles of women. ”Too often our own ignorance, fear and denial have held us back as teachers about HIV/AIDS and its impact on children, women and young people,” the leaders said in a closing statement.
However, both Christian and Muslim religious leaders declined to endorse the use of condoms, opting instead for sexual abstinence and fidelity within marriage.
Bertha Sefu of the Malawi Council of Churches said men were the main problem in spreading AIDS in Malawi, one of the hardest-hit countries in southern Africa. “Eighty percent of wives in Malawi consistently say they have known no other man than their husband but there are thousands of orphans in our country. Malawian men need to recommit themselves to their marriages before the orphans come. The only means of avoiding HIV/AIDS is through abstinence.”
Stephen Lewis, undoubtedly one of Canada’s finest speakers and a passionate advocate of social justice for most of his life, is a former Canadian ambassador to the United Nations and is now a special UN envoy to Africa on AIDS.
During a recent interview on Canadian television, Lewis’ outrage was tightly controlled and just below the surface. Calling AIDS a “monumental devastation” of humanity, he stripped bare the leadership of the most powerful and wealthy nations as they met in Alberta to determine the world’s financial and economic priorities for the next year.
“Unless these epidemics (AIDS, tuberculosis and malaria) are brought under control, any gains in human development will remain an impossible hope.”
“I get very emotional about the subject of AIDS in Africa,” he continued. “Some of my good friends worry about my psychological equanimity. I guess they think men are supposed to be stoic and bravely unfeeling.”
But, in a lifetime of battling injustice as a Canadian political leader and a world spokesperson for the downtrodden, Lewis says, “I’ve never seen anything like this. I don’t know how to get a grip on it. I don’t know how to make sense of it. Is the behaviour of the western world just appallingly insensitive? Is it unacknowledged racism? Is it sheer unbridled indifference? Is it the comfortable assumption of hopelessness in order to avoid contributing money? Or is it possible that the political leadership is completely out of touch with the vast populations — like the people of Canada — over whom it holds sway?”
Here is one of many haunting images of Africa: young mothers sitting on makeshift benches under a tree in Zambia, 15 or 20 of them, all of them exhibiting AIDS-related symptoms, and urgently, with great dignity, asking who will care for their soon-to-be-orphaned children, asking about only heard-of medications, how to treat their infections.
And there are no answers because their leaders and our leaders do not have the political will.
Yet there are solutions. But they require a basic change in global thinking.
For many years conventional economic wisdom has said that if enough economic growth is generated, the health of a society will be secured. It’s essentially the old and discredited trickle-down theory.
However, a remarkable study by Jeffrey Sachs, a former Harvard economist and now special adviser to UN Secretary General Kofi Annan, shows that “the reality of AIDS means that nothing short of a new approach to Africa will work.”
Sachs argues: “The burden of disease in sub-Saharan Africa stands as a stark barrier to economic growth and therefore must be addressed frontally and centrally in any development strategy. The AIDS pandemic represents a unique challenge of unprecedented urgency and intensity. This single epidemic can undermine Africa’s development growth over the next several generations.”
Sachs’ plan works two ways. He will not let the African leaders off the hook. Their lack of transparency, weak governance and corruption must be addressed and cleaned up. In return, our leaders, our peoples must “simultaneously commit vastly increased financial assistance, in the form of grants not loans, especially to the countries that need help most urgently which are concentrated in sub-Saharan Africa.”
Then in the only sentence in his report which is italicized, Sachs writes: “[The Western nations] should resolve that lack of donor funds should not be the factor that limits the capacity to provide health services to the world’s poorest peoples.”
That’s the rub and that’s the rot. The West, very much including Canada, has failed its own moral standards. In 1970, the late prime minister Lester Pearson chaired a meeting of wealthy nations which pledged that seven-tenths of one percent of Gross Domestic Product (GDP) — the infamous .7 percent of GDP — would be the foreign aid quota for the wealthy nations. No one has even come close to meeting that pledge.
The current official development assistance for all wealthy nations is .22 percent or about US$53 billion for the entire developing world. If it were .7 percent it would yield US$175 billion this year and US$210 billion by 2005.
By any rational standards there would be more than enough money to staunch the AIDS pandemic, provide free universal education and deal with poverty, hunger and lack of water and sanitation.
Everyone wants to get on the AIDS bandwagon for free. There have been dozens of proposals such as the one made by Chrétien to increase the budget of the Canadian International Development Agency (CIDA) by eight percent until CIDA’s aid is doubled around 2008. However, we are not reminded of how gutted CIDA’s budget has been by the present administration over the last nine years. Chrétien’s proposed increase would bring CIDA’s budget back to about 1985 levels.
Last year at the AIDS summit held in Abuja, Nigeria, Kofi Annan formally proposed a Global Fund for AIDS, tuberculosis and malaria which would generate US$10 billion from all sources, especially governments. After months of cajoling, pleading and begging, the rich nations came up with pledges of US$2.21 billion spread over three years — about seven percent of what was needed.
Lewis calls it “international financial delinquency.”
Sachs concludes his stirring plan by saying: “There is no excuse in today’s world for millions of people to suffer and die each year for lack of the US$34 per person needed to cover essential AIDS health services. A just and far-sighted world would not let this tragedy continue.”
While the situation in Africa and, increasingly, other parts of the developing world is apocalyptic, it can be addressed. It can be defeated now that we know how. We may not have the vaccine that some scientists hope for but as the 14th International AIDS Conference in Barcelona in July said, the world is ready to take on the AIDS pandemic 21 years after it first emerged.
In Africa there is a desperate need for voluntary counselling and testing. There remains only to train the counsellors and get the rapid testing kits in the proper hands.
Prevention of mother-to-child transmission using a new drug, nivarapine, works in 53 percent of cases and involves one tablet during labour, one dose for the infant within hours of birth and thousands of lives are saved. The standard cocktails, while still far too expensive and inappropriate for decimated public health systems, are ready when the money to rebuild health services comes. Less than US $1-a-day.
Street theatre in key youth communities across Africa using music, dance, drama, drums and poetry raises awareness of sexuality, abstinence and behavioural change.
Women of Africa are the strongest people I know — anywhere. They battle for life from village to legislature. Their networks of community and faith-based organizations provide care, compassion and love where there is stigma, fear and isolation.
Women know that AIDS is a gender-based disease as well as a poverty-based disease. Predatory male behaviour is being tested and rejected as a “cultural” right by more and more women. High-risk groups such as soldiers, truck drivers and sex workers are being targeted.
There is no doubt the problems are overwhelming, that funerals are now the most common form of social gathering, that hospitals are wards of horror and that cultures and societies are being strangled.
If the tepid response of the G8 and the more realistic attitude of Barcelona, along with plans such as Jeffrey Sachs’ and a new initiative from the Lancet, a leading medical journal that promises eradication of HIV for US$27 billion between now and 2010, can merge with creative and dynamic political leadership supported by the churches and other faith groups, the impending apocalypse may be averted.
There is a common enemy, Kofi Annan says, that knows no frontiers of rich and poor, developed or developing. The war on AIDS must take precedence for moral as well as pragmatic reasons.
(Veteran Canadian journalist Hugh McCullum covered the AIDS pandemic from Africa for more than 12 years.)
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