[CTRL] Aids-Death Watch in Three Parts

[J Taylor]

>Here are all three parts of a Washington Post series on AIDS in Africa.
>
>DEATH WATCH: The Global Response to AIDS in Africa
>By Barton Gellman Washington Post Staff Writer
>Wednesday, July 5, 2000 ; A01<P>
>
>First of three articles<P>
>
>>From a seventh-floor office in Langley some 13 years
>ago, Katherine J. Hall kept vigil on the unraveling of
>societies and states.<P>
>
>As national intelligence officer at large, Hall
>supervised the CIA's taxonomy of upheaval overseas.
>What signs forecast a government's collapse, an
>economy's ruin, a civil war? Hall and her staff had a
>hunch that conventional indicators, heavy on politics
>and money, were missing something. In 1990, after three
>years of frustrated lobbying, she and colleague Walter
>L. Barrows got permission to study the burgeoning
>growth of AIDS.<P>
>
>Interagency Intelligence Memorandum 91-10005,
>distributed in classified channels the following July,
>foretold one of the deadliest calamities in human
>experience. Titled simply, "The Global AIDS Disaster,"
>the report projected 45 million infections by
>2000--inexorably fatal, the great majority in Africa.
>The number beggared comparison. There were not that
>many combatants killed in World War I, World War II,
>Korea and Vietnam combined.<P>
>
>Unlike the Black Death in 14th-century Europe, which
>took half as many lives, the means of controlling AIDS
>were known. Yet African and foreign governments, the
>report said, were making no more than a "modest level
>of effort." This would "have only a marginal
>effect."<P>
>
>The same might have been said for IIM 91-10005. The
>document landed near the top of the pile of incoming
>intelligence at the White House and Cabinet agencies.
>The reaction, said principal author Kenneth Brown, was
>"indifference--that's the right word." The authors
>prepared for the flurry of briefings that accompanies
>release of a major intelligence product. Save for
>then-Surgeon General C. Everett Koop and a Pentagon
>medical unit, no one asked.<P>
>
>Nine years later, a highly public awakening plays out
>in the Clinton administration, Congress, foreign
>capitals, the United Nations system and the offices of
>drug manufacturers. The premise of their new
>commitments on AIDS is that they are confronted for the
>first time with the magnitude of the disaster.<P>
>
>Yet for a decade, the world knew the dimensions of the
>coming catastrophe and the means available to slow it.
>Estimates ranged widely, but the World Health
>Organization in 1990 and 1991 projected a caseload, and
>eventual death toll, in the tens of millions by 2000.
>Individually and collectively, most of those with power
>decided not to act.<P>
>
>How and why they made their choices is the subject of
>this series of articles. It is a story of authentic
>doubts for a time because the disease concealed itself
>in years of latency and layers of social taboo. It is
>also a story, by turns, of willful ignorance and
>paralysis in the face of growing proof. Its direction
>is marked by wealthy nations' loss of interest once
>they understood they had escaped the worst, by racial
>undercurrents, and by poisonous turf battles among the
>multinational bodies charged with marshaling a
>response. At nearly every level, the process featured
>what some participants now see as shameful "demand
>management": reluctance to take available steps for
>fear of prompting still greater claims on time and
>money.<P>
>
>"The first reaction is, 'That's impossible. We could
>never spend those kinds of resources,' " said William
>H. Foege, who directed the federal Centers for Disease
>Control and Prevention (CDC) until 1983, speaking of
>1990s estimates that it would take as much as $3
>billion a year to fund global AIDS prevention. "Then
>you have to remember, that's how much we spend on
>health care in the United States every day. It makes
>you wonder what's wrong with us, and how will history
>judge our response."<P>
>
>If today marks a turning point, it is too late for
>nearly all the 34.3 million people now living with HIV
>and AIDS, and for the many who will follow. Fewer than
>2 percent of them have access to life-prolonging
>therapies of antiretroviral drugs, or even basic
>treatment for secondary disease. "They're all dead
>already," said one despairing U.S. health official.
>"They're just still walking around."<P>
>
>Nor has the wave begun to crest. The number of new
>infections with HIV, the human immunodeficiency virus
>that causes AIDS, is estimated at 15,000 a day--and
>still growing. The United Nations has set a goal to cut
>new infections by 25 percent by 2005, but even that
>improbable feat would not stop the toll from doubling
>and doubling again.<P>
>
>"We are at the beginning of a pandemic, not the middle,
>not the end," said Sandra Thurman, director of the
>White House Office of National AIDS Policy. "We
>certainly know before we're able to stop this pandemic
>we'll have hundreds of millions of people infected and
>dead, and that's the best case scenario."<P>
>
>James Sherry, director of program development for the
>Joint United Nations Program on HIV/AIDS, or UNAIDS,
>finds it difficult to speak of the wasted lives without
>bitterness.<P>
>
>"I can't think of the coming of any event which was
>more heralded to less effect," he said. "It still
>hasn't changed. It hasn't changed. In terms of real
>redeployment of resources, it hasn't changed. The
>bottom line is, the people who are dying from AIDS
>don't matter in this world."<P>
>
>'Under Their Noses'<P>
>
>The 1990 CIA projection turned out to be optimistic.
>Less than 20 years after physicians first described its
>symptoms, HIV has infected 53 million people. So far,
>19 million have died, roughly the population along the
>Amtrak route from New York to Washington. Especially in
>Africa, but also elsewhere in the developing world,
>basic measures of well-being are marching backward.
>AIDS, by itself, is reversing decades of slow
>improvement in child survival, adult longevity,
>educational attainment and economic growth.<P>
>
>When Brown and Hall first proposed to study the
>phenomenon in 1987, they could not obtain CIA approval
>for use of personnel and computer modeling resources.
>Internal critics declared global AIDS an unfit subject
>of intelligence, or said the impact on U.S. interests
>would be benign.<P>
>
>Speaking of one military colleague at the National
>Intelligence Council, Brown said, "His penetrating
>analysis was, 'Oh, it will be good, because Africa is
>overpopulated anyway.' Others were saying, 'It may be
>big, but what are you going to do about it?' " Still
>others, Brown recalled, discounted the likelihood of
>damage to allied militaries. If officers began dying of
>the disease, they said, "That boosts morale, because
>there's more room for advancement."<P>
>
>Another security official, recalling those debates,
>said critics reasoned that Africa's limitless pool of
>unemployed men left armies with plenty of
>reinforcements. "If you have one 18-year-old with a
>Kalashnikov [rifle] and he dies, you find another
>18-year-old," he said. "The cold truth was that the
>impact on military stability was minimal."<P>
>
>But the chairman of the intelligence council, Fritz
>Ermarth, saw a winning argument in the AIDS pitch. "I
>said, 'This is one of those new-age issues, and nobody
>else is doing it,' " he recalled.<P>
>
>Ermarth's only hesitation, shared by William H.
>Webster, then the director of central intelligence,
>involved the "propaganda liabilities of associating
>this painful topic with the CIA." Soviet era
>disinformation charged the CIA with brewing the virus
>for germ warfare. Barrows remembers anxieties that
>"somebody would try to imply that we're only monitoring
>our own dastardly deeds."<P>
>
>In the end the CIA agreed to undertake the work and let
>the State Department publish unclassified portions as a
>white paper. In that form in 1992, it reached a wider
>readership with predictions of "life expectancy at
>birth reduced by 15 years or more" and infection rates
>of "10 to 30 percent of the sub-Saharan African
>population," both of which closely match today's
>reality.<P>
>
>By any account, little or no fresh response followed
>the report.<P>
>
>"You've got to have a critical mass of people that are
>primed to see a problem like this in strategic terms,"
>Ermarth said. "Just to put the words under their noses
>. . . doesn't get their attention. It's kind of remote,
>it's distant, it's not obvious what you do about it
>anyway. And here you're talking 1991, and that critical
>mass didn't exist."<P>
>
>In the first U.S. budget submitted after IIM 91-10005,
>appropriations for AIDS control overseas measured
>$124.5 million, just over half of what Americans pay
>annually for baldness therapy. Spending remained flat
>at that level for seven years. And those budgets, in
>global context, were considered high. The combined
>assistance from Europe, Australia and Japan barely
>surpassed them. The Bush and Clinton administrations
>entertained no proposal to increase the funding.<P>
>
>Over that seven-year period, as best can be calculated
>from U.N. data, 17,873,939 men, women and
>children--three-fourths of them in Africa--contracted
>an infection that has or will soon cut short their
>lives.<P>
>
>Discovery, Doubt, Denial<P>
>
>Summoned by improbable theory, a small team of foreign
>scientists touched down in Kinshasa, Zaire (now Congo),
>on Oct. 18, 1983. People were dying mysteriously at
>Mama Yemo Hospital, the 2,000-bed facility named for
>the president's mother. Bila Kapita, chief of internal
>medicine there, had followed medical reports of a new
>immune disease identified in San Francisco and New
>York. He wanted to know whether he could be seeing it
>in Zaire.<P>
>
>Peter Piot, a 34-year-old Belgian who had co-discovered
>the Ebola virus in his twenties, led the team of
>specialists from the CDC and the National Institutes of
>Health. He had been to Mama Yemo in the Ebola days, and
>he saw at once how much had changed.<P>
>
>"In 1976, there were hardly any young adults there
>except for traffic accidents in orthopedic wards," Piot
>recalled. "Suddenly--boom--I walked in and saw all
>these young men and women, emaciated, dying."<P>
>
>There was not yet an antibody test for the AIDS virus.
>It took three weeks of makeshift laboratory
>work--counting T-cells and lymphocytes in blood
>samples, confirming secondary infections associated
>with the new disease--to validate Piot's snap
>diagnosis. There were some three dozen AIDS cases in
>the hospital, and they were divided almost evenly
>between women and men.<P>
>
>The implications staggered Piot and his American
>colleague, Joe McCormick.<P>
>
>"There were so many women, it said to me it's
>heterosexual," Piot said. "That means everybody's at
>risk. . . . Until then I never thought a whole country,
>a whole population, could be involved."<P>
>
>Few believed the report from Zaire. The illness had
>been known since 1981 as Gay-Related Immunodeficiency
>Disease. Only homosexual contact, apart from direct
>exposure to infected blood, was thought to transmit the
>virus.<P>
>
>Piot, Kapita and McCormick found their submission
>rejected by a dozen medical journals. Peer reviewers
>asserted adamantly that the team must have overlooked
>some alternate path of transmission. At the first
>international AIDS conference two years later in
>Atlanta, "people came up to us and said this is
>nonsense," Piot said. "Denial has been a characteristic
>of this epidemic at all levels."<P>
>
>Governments shared much of the same disbelief. The
>first reports of AIDS closely followed the inauguration
>of President Ronald Reagan, whose "family values"
>agenda and alliance with Christian conservatives
>associated AIDS with deviance and sin. "AIDS is God's
>punishment," Rev. Jerry Falwell said in a famous 1983
>television sermon, paraphrasing liberally from
>Galatians 6:8. "The Scripture is clear: We do reap it
>in our flesh when we violate the laws of God."<P>
>
>McCormick, Piot's CDC colleague on the Kinshasa trip,
>asked the Reagan administration for funding to return
>to Zaire to conduct a larger study. According to Laurie
>Garrett, author of "The Coming Plague," political
>appointees turned McCormick down, refusing to believe
>his finding that "AIDS can be, and is, a heterosexual
>disease."<P>
>
>The Fears of the Rich<P>
>
>Projet SIDA, after the French acronym for AIDS, went
>forward in Kinshasa without White House help, despite
>McCormick's plea. Leading it, fresh from a public
>health surveillance post in New Mexico, came a young
>American doctor who would transform the global AIDS
>campaign.<P>
>
>Jonathan Mann, then 37, brought passion and meticulous
>energy to the job. From 1984 to 1986, his small team
>traced widening circles of infection, without apparent
>social boundaries, in Zaire. "The harder Jon and his
>team looked for identifiable risk factors, the more
>they came to realize the worst," Robert W. Ryder, who
>took over the project from Mann, wrote later. "The risk
>factors for HIV infection in Kinshasa were being young
>and sexually active and living in Kinshasa."<P>
>
>One unknown variable stood out when scientists gathered
>in Bilthoven, Netherlands, in 1986. "You need to know
>who is having sex with whom," but few human
>interactions are so bound up in concealment and taboo,
>said Bernhard Schwartlander, now chief of epidemiology
>at UNAIDS. "The big problem is that we had no idea of
>the mixing patterns."<P>
>
>This much was clear: With heterosexual transmission
>established, AIDS might go anywhere. Mann became
>convinced the disease had "transcendental importance"
>and compared it to tectonic forces shaping a continent.
>He was a persuasive salesman, and two years of evidence
>gathered in Zaire pierced the complacency of many
>governments.<P>
>
>Early in 1986, the World Health Organization in Geneva
>still regarded AIDS as an ailment of the promiscuous
>few. Halfdan Mahler, the organization's Danish-born
>director general, enraged Piot with a casual suggestion
>in one early meeting that other diseases were far more
>important than AIDS.<P>
>
>Fakhry Assaad, Mahler's chief of infectious diseases,
>was beginning to disagree. He knew Mann's research, and
>the two men made common cause at a conference that year
>in Bangui, Central African Republic, where the din of a
>tropical downpour on a sheet iron roof broke up the
>proceedings and gave them time to talk. Assaad brought
>Mann to Geneva in November. In a two-hour conversation,
>the charismatic American upended Mahler's view of the
>world.<P>
>
>AIDS was not merely another infectious disease, Mann
>argued. It seemed to flourish in--and
>reinforce--conditions of poverty, oppression, urban
>migration and social violence. It therefore could not
>be solved as a biomedical problem. Women who feared a
>beating would not ask their husbands to use condoms.
>Street children and widows without rights of
>inheritance could not reduce the number of their sexual
>partners if they depended on sex for subsistence.<P>
>
>In an interview with filmmaker Robert Bilheimer before
>Mann's Sept. 3, 1998, death in the crash of Swissair
>Flight 111, Mann said discrimination "isn't just an
>effect, it's actually a root cause of the epidemic
>itself."<P>
>
>Mahler later described himself as transformed by Mann's
>analysis. On Nov. 20, 1986, less than three weeks after
>meeting Mann, the WHO leader flew with him to New York
>for a news conference. A few minutes before 1 p.m.,
>they walked together into Room S-0226 at U.N.
>headquarters.<P>
>
>"We stand nakedly in front of a pandemic as mortal as
>any pandemic there has ever been," Mahler declared. "In
>the same spirit that WHO addressed smallpox
>eradication, WHO will dedicate its energy, commitment
>and creativity to the even more urgent, difficult and
>complex task of global AIDS prevention and control."<P>
>
>Those were stunning words from a man who had helped
>make the smallpox program the organization's greatest
>achievement, then or since. Back in Geneva, he put Mann
>in charge of a special program on AIDS that bypassed
>WHO's chain of command. Mann's operation grew headlong
>from a single room and secretary to one of the
>organization's biggest programs.<P>
>
>"It was such an incredible turnaround," recalled
>Kathleen Kay, an Australian who became Mann's first
>hire and longtime deputy. The first year, 1987, brought
>a crescendo of political and financial commitments,
>including a special session of the U.N. General
>Assembly. January 1988 saw the largest gathering of
>health ministers ever assembled, 118 in one room.<P>
>
>"We went into that meeting at minus $500,000 and we
>left with $37 million," said Kay, who is now writing
>her doctoral dissertation on the period. The program
>grew as fast as it could absorb people and cash, and
>often faster. Contributions from the U.S. Agency for
>International Development--the largest of any
>nation--began at $6.6 million in 1987 and more than
>doubled in each of the next two years.<P>
>
>But the seeds of Mann's undoing, and the program's, had
>already been sown. Abundant resentments in the WHO
>secretariat began to surface after Mahler's surprise
>decision to retire in 1988. Mahler's replacement,
>Hiroshi Nakajima, had been director of Pacific
>operations for the WHO and shared general displeasure
>at Mann's privileged status and unorthodox style. A
>master of back-room maneuvering, Nakajima began to clip
>the AIDS program's wings.<P>
>
>By 1990, the sense of urgency about AIDS in wealthy
>nations had also started to dissipate. "In the '90s it
>became clear we were not going to have a major
>heterosexual epidemic in the States," said Michael
>Merson, who would succeed Mann at the WHO program. AIDS
>"was no longer a threat to the West."<P>
>
>Foege, the former CDC director, now teaches at Emory
>University. He has a maxim for his public health
>students: "Tie the needs of the poor with the fears of
>the rich. When the rich lose their fear, they are not
>willing to invest in the problems of the poor."<P>
>
>'Like a Slow Torture'<P>
>
>Albina du Boisrouvray, a French countess who auctioned
>off a Renoir and tens of millions of dollars' worth of
>jewelry at Sotheby's to fund her philanthropy against
>AIDS, remembers traveling to Geneva to confront
>Nakajima early in his term at the WHO. "I said, 'Aren't
>you worried about AIDS?' He said, 'Ah, don't talk to me
>about AIDS; I have malaria, which is a much bigger
>killer of people, on my hands.' "<P>
>
>And for a time, malaria was. But AIDS was growing
>exponentially; malaria was not. As a scientist,
>Nakajima understood the implications. But a U.S.
>official who worked with him then said Nakajima
>concentrated on the constituency politics of
>reelection. That meant providing money for popular
>programs, not drawing attention to a problem that few
>nations wished to acknowledge.<P>
>
>"It was all demand management," the U.S. official
>said.<P>
>
>Inside Nakajima's secretariat, institutional rivals of
>the AIDS program told him that Mann's program was
>excessive for the tiny number of AIDS cases that could
>be proved, according to WHO senior manager Marjory Dam.
>Nakajima set out to "normalize" the special program's
>status, cutting resources and subjecting it to layers
>of unsympathetic management.<P>
>
>A week or so before the first World AIDS Day summit on
>Dec. 1, 1988, Mann obtained an advance transcript of an
>interview Nakajima had given to the French newspaper Le
>Monde. He was appalled. Among other things, Nakajima
>implied the need for balance between the rights of AIDS
>patients and the interests of society at large. Mann
>saw that as a green light for the kinds of bans on
>immigration and employment of people with AIDS that WHO
>experts said were driving the pandemic underground.<P>
>
>According to Kay, Mann's deputy, Mann made urgent
>efforts to reach Nakajima, who was traveling. The
>director general's new aides rebuffed him, pointedly.
>Kay, who witnessed what came next, said Mann then
>delivered an ultimatum: If Nakajima's remarks were
>published, Mann would quit--in his keynote address to
>the coming summit. Nakajima could not afford such a
>spectacle. He retracted and rewrote his remarks to Le
>Monde, and Mann never mentioned them again. But
>Nakajima would not forget.<P>
>
>Mann found himself excluded from meetings. The legal
>authority to spend his budget sat unsigned on
>Nakajima's desk. His travel requests were denied,
>anonymously and without explanation, or granted too
>late to matter.<P>
>
>"The WHO's AIDS program pretty much fell apart," said
>Thurman, the White House AIDS director.<P>
>
>On March 16, 1990, Mann took defiant leave of the
>scene. At the very hour that Nakajima unveiled six
>ceremonial stamps for the fight against AIDS--an apt
>symbol of the director general's priorities, Mann
>believed--Mann convened his staff just across the hall.
>He told them he was quitting. His letter to Nakajima
>cited "great variance between our positions on a series
>of issues which I consider critical for the global AIDS
>strategy."<P>
>
>Nakajima did not return telephone calls seeking an
>interview for this article. His wife, Martha Nakajima,
>reached at the couple's summer home in Chauvigny,
>France, said he was not "particularly interested in
>rehashing things with Jonathan Mann. . . . He's retired
>now. He doesn't owe anybody anything on that."<P>
>
>Kay, who quit the program with Mann, recalled those
>years as "just soul-destroying." She added: "To see the
>structures grinding to a halt. Just dreadful. All those
>years lost! It was like a slow torture."<P>
>
>Mann intended to depart in June, but on March 23 Le
>Monde published an interview in which Mann accused
>Nakajima of obstruction that "paralyzed our efforts
>completely." He was ordered to clear his desk by the
>end of the day.<P>
>
>'Indifference'<P>
>
>The World Health Organization was not the only agency
>trying to protect its resources from the demands of
>AIDS. Most major contributors to global health and
>development followed the pattern.<P>
>
>Throughout the early and mid-1990s, the Clinton
>administration debated the merits of paying for AIDS
>testing and counseling of vulnerable populations
>overseas. Among gay men in the United States, such
>programs had been credited with causing substantial
>change in risky behavior--increasing condom use and
>marginalizing the culture of promiscuous "bathhouse"
>sex.<P>
>
>The CDC and U.S. Agency for International Development
>(USAID) held out for years against paying for AIDS
>tests overseas. The only exception was traditional
>"surveillance" to track the pandemic's growth, but
>those results remained anonymous. Individuals who
>tested positive were not informed.<P>
>
>"The argument was that testing was too expensive, and
>it led to things that were more expensive," said
>Gregory Pappas, a physician and Health and Human
>Services official who took part in the debate in those
>years. "The philosophy in development circles was,
>don't create demand. The implications of a lot of
>people knowing that they have HIV, instead of just
>dying of it, is [that] it creates demands on the
>development assistance agencies. It's a calculation
>that they're trying to postpone paying for
>interventions that they don't think they can
>afford."<P>
>
>Beaten down by years of congressional attacks on
>foreign assistance, and on family planning especially,
>USAID did not propose budget increases to contend with
>AIDS. In international forums, participants said, the
>agency concentrated on limiting the U.S. contribution
>to 25 percent of the global total. Other countries, and
>U.N. agencies, were spending so little on AIDS
>assistance that the American share climbed as high as
>47 percent by 1997.<P>
>
>In truth, the principal U.S. foreign aid agency was
>trying to disentangle itself from mandatory funding of
>AIDS programs. Mann, who had taken his charismatic
>advocacy to Congress in the late 1980s, had persuaded
>appropriators to earmark portions of the agency's
>budget for his Geneva-based program. According to
>interviews and internal memorandums made available to
>The Washington Post, USAID focused much of its
>legislative energy on eliminating or reducing the
>earmark in order to recapture control of its budget.<P>
>
>Duff Gillespie, who oversaw AIDS assistance as director
>of USAID's programs on population, health and
>nutrition, argued that overpopulation was
>overwhelmingly the most important problem for Africa.
>"Duff was very much worried about not letting the
>population budget be used for AIDS," said Merson, who
>succeeded Mann as chief of the WHO program.<P>
>
>In a revealing memorandum composed in March 1998,
>Gillespie tried to explain "the lack of political will
>and resources to combat the spread of HIV." He
>emphasized the importance of remembering that
>"decisions made by policymakers and program
>administrators are almost always based on a rational
>process." It would be wrong to suppose that such
>decisions were "based on gross ignorance, or morally
>bankrupt." Most commonly they were "simply the product
>of a different world view and set of priorities."<P>
>
>When decision makers divided their available funds for
>foreign aid, he wrote, the AIDS pandemic had many
>disadvantages. There was no tool available that
>"directly and invariably" prevents transmission. There
>was no cure. Costs of AIDS programs were high, and the
>afflicted populations often lacked "an inherently
>sympathetic 'victim.' "<P>
>
>Nor, in the view of Gillespie and many other foreign
>aid professionals in the 1990s, were AIDS interventions
>cost-effective. To save the life of a dehydrating child
>with diarrheal disease required little more than a foil
>packet of salts. Antibiotics cured an otherwise fatal
>case of tuberculosis. What USAID and other agencies
>craved were programs that would demonstrate efficacy in
>congressional audits.<P>
>
>"Do we enter into fields where our interventions have
>the biggest bang for the buck?" asked Dennis Aitkin, a
>British career administrator at the WHO. "If tomorrow
>there was disease out of the blue that you could cure
>with a hundred million dollars per person, would we
>focus on it at all?"<P>
>
>At UNICEF, the U.N. children's agency, the health
>division fought a bitter rear-guard battle from 1992 to
>1994 to avoid involvement in AIDS. Sherry, the director
>of program development at UNAIDS, was then a senior
>health administrator at UNICEF, and used the post to
>expand UNICEF's traditional early childhood mission to
>include teenagers contracting a sexually transmitted
>plague.<P>
>
>In a small sign of things to come, Sherry's secretary
>quit because he was asking her to handle correspondence
>mentioning condoms. Then UNICEF's child immunization
>department organized a mass threat to resign. "Why are
>we jeopardizing our relations with the Holy See?" one
>angry colleague demanded of Sherry, referring to
>Vatican opposition to birth control.<P>
>
>At the World Bank, an internal study found what South
>African economist Alan Whiteside ridiculed as a "silver
>lining" in the plague.<P>
>
>"If the only effect of the AIDS epidemic were to reduce
>the population growth rate, it would increase the
>growth rate of per capita income in any plausible
>economic model," said the June 1992 report by the
>bank's population and human resources department.
>Exactly that had happened in the 14th century, the
>report said, with the bubonic plague. The report did
>not conclude that AIDS would be a benefit to Africa,
>even in strictly economic terms, but it hardly marked a
>clarion call to action.<P>
>
>"Only the World Bank would put that on paper,"
>Whiteside said.<P>
>
>'Abdication'<P>
>
>By the middle 1990s, two new trends took shape. In the
>wealthy industrialized nations, effective drug
>therapies against AIDS became available--AZT as early
>as 1987, then combinations of antiretroviral agents in
>1996. The new drugs offered hope that fatal
>complications might be staved off and AIDS rendered a
>chronic condition. In theory, the drugs gave
>authorities their first plausible lifeline to AIDS
>victims overseas as well. In practice, they diminished
>the urgency of the enterprise by convincing the
>developed world that it would escape the pandemic
>without grave effects.<P>
>
>Until the advent of these therapies, said David
>Nabarro, then chief of health programs for the British
>Department for International Development, one obstacle
>to AIDS assistance was "the notion that if you got the
>virus, there was [nothing] that could have been done
>for you." Now that effective prevention and treatment
>had come of age, the wealthy nations had to decide what
>they thought a life saved in Africa was worth.<P>
>
>"The bottom line," Mann told his filmmaking partner,
>Bilheimer, "is that the epidemic could rage on in
>Africa and we could control it here. . . . We're the
>rich United States. Do we need Africa?"<P>
>
>Policymakers did not contemplate attempts to bring the
>expensive new drug cocktails to Africa, in part because
>of the pharmaceutical cost and in part because most of
>the continent lacked the health care apparatus to
>dispense them.<P>
>
>"Transplantation of Northern interventions to the
>South," Gillespie wrote, would "siphon off resources"
>with "limited or no impact on the course of the
>pandemic."<P>
>
>Mann's departure from the WHO, meanwhile, had not
>halted the AIDS program's slide. Although he tried to
>be a good soldier, Mike Merson was as frustrated as his
>predecessor had been.<P>
>
>To open the ninth international conference on AIDS in
>Berlin on June 7, 1993, Merson unveiled new
>research--based in part on work at the London School of
>Hygiene and Tropical Medicine--that calculated for the
>first time what it would cost to prevent half of the 20
>million new infections projected by 2000: $2.5 billion
>a year, or about 20 times the global AIDS budget.<P>
>
>"The world can find this kind of money when it wants
>to," Merson said.<P>
>
>Such sermons tended to be preached to the faithful. Who
>else attended AIDS conferences? In many governments,
>officials of the era still professed to be unaware of
>the pandemic. "From the U.K. perspective, there was
>absolutely no sense that AIDS would become the critical
>emergency it has become at the moment until 1994,
>1995," said Julia Cleves, who worked for the British
>Department for International Development.<P>
>
>In Geneva, epic struggles were underway to control the
>bureaucratic turf around AIDS. The U.N. Development
>Program, in particular, attacked Merson's program as
>hopelessly focused on biomedical needs, ignoring the
>roots of AIDS in underdevelopment. Kathleen Cravero, a
>Merson aide, became his intermediary with officials
>with whom he was not on speaking terms.<P>
>
>In 1994, donor governments began pushing for creation
>of a joint U.N. AIDS program. Two years passed in
>further acrimony over control of its funding and
>administration. The WHO spent many months, for example,
>attempting to impose language saying it would
>"administer" the program rather than offer
>"administration in support" of it--at bottom, a
>question of power.<P>
>
>The World Bank, one of six cosponsors of the joint
>program, emphasized that it would "assume no liability"
>for UNAIDS and wished to have "as little involvement as
>possible" in the new unit, according to memos in 1995
>from legal adviser Louis Forget and human development
>director Richard Feachem.<P>
>
>When UNAIDS was finally established on Jan. 1, 1996,
>its ostensible partners cut back sharply on the
>resources and personnel they devoted to AIDS. World
>Bank loans dropped from $50 million to less than $10
>million, WHO spending dropped from $130 million to $20
>million, UNICEF from $45 million to $10 million, and so
>on.<P>
>
>Inside UNAIDS, advisers to Peter Piot--the Belgian
>virologist, who had become its first director--were
>speaking of a "syndrome of abdication."<P>
>
>The summer of 1998 brought a new director general to
>WHO, former Norwegian prime minister Gro Harlem
>Brundtland. In early speeches and her first two reports
>on the state of health in the world, she emphasized
>tobacco and tuberculosis and seldom mentioned AIDS.<P>
>
>In an interview at her headquarters, Brundtland said
>AIDS had already been identified by U.N. member states
>as a global health priority, and in any case Piot's
>UNAIDS program operated side by side with her in
>Geneva. "If I had announced that my major priority for
>WHO would be AIDS," she said, everyone would have
>assumed she planned to refight her predecessor's
>battles with the program. "I was absolutely certain
>that to create a stir-up which would be interpreted as
>infighting would be the last thing we should do," she
>said.<P>
>
>Last year, HIV/AIDS reached a long-expected milestone
>in the WHO's surveillance of disease and death: It
>surpassed all other causes of death in Africa. That
>fact was nowhere mentioned in the text of Brundtland's
>1999 World Health Report.<P>
>
>At UNAIDS, officials drafted a press release and urged
>the WHO to publish it.<P>
>
>Schwartlander, the senior epidemiologist at UNAIDS,
>also prepared a briefing slide on the new mortality
>data for use by his sister organization. Brundtland's
>organization released neither document, and mid-level
>officials said new prominence for AIDS would bring
>pressure on other health budgets in rival
>departments.<P>
>
>Today, in a secretariat of 2,000, the WHO has nine
>professionals who work full time on AIDS.<P>
>
>Black and White<P>
>
>The CIA updated its AIDS projections in two major
>studies after 1991. National Intelligence Estimate 95-5
>largely reaffirmed the earlier results and noted that
>the world spent 10 percent of its AIDS prevention
>budget "in developing countries, where 85 percent of
>all infections occur." That report had no more impact
>than its predecessor, except on military planners who
>learned of the disease's implications as "a potential
>'war-starter' or 'war-outcome-determinant.' "<P>
>
>The next major AIDS study came in National Intelligence
>Estimate 99-17, released in unclassified form in
>January. That one resulted from, and intensified, a
>sudden urgency in the Clinton administration to act. No
>important feature of the epidemic had been discovered
>in a decade. What mobilized the government, after seven
>years of modest effort, has been difficult for its
>policymakers to identify.<P>
>
>Nowadays Treasury Secretary Lawrence H. Summers and
>national security adviser Samuel R. "Sandy" Berger
>often speak publicly about AIDS, and both have pressed
>for increased resources. In January, the U.S.
>ambassador to the United Nations, Richard C. Holbrooke,
>orchestrated a special session of the U.N. Security
>Council to discuss AIDS.<P>
>
>Holbrooke announced his plan to focus on Africa late
>last year. Arriving on the continent for a preparatory
>visit, Holbrooke said in an interview, "it occurred to
>me we were going to have the presidency of the Security
>Council in January, the first month of the new
>millennium. We needed a theme."<P>
>
>Looking around the policy landscape, Holbrooke came to
>see AIDS as "the most important problem." He found an
>ally in Leon Fuerth, national security adviser to Vice
>President Gore. Holbrooke proposed a visit by Gore to
>the council to "really dramatize" American urgency. It
>did not hurt his proposal, other officials said, that
>Gore had been tormented by AIDS activists in his
>campaign for the Democratic nomination for
>president.<P>
>
>On Jan. 10, Gore strode into the 4,086th meeting of the
>Security Council and spoke of the world's moral duty to
>"wage and win a great and peaceful war" against
>AIDS.<P>
>
>"Today, in sight of all the world," he declared, "we
>are putting the AIDS crisis at the top of the world's
>security agenda. We must talk about AIDS not in
>whispers, in private meetings, in tones of secrecy and
>shame. We must face the threat as we are facing it
>right here, in one of the great forums of the
>earth--openly and boldly, with urgency and
>compassion."<P>
>
>Thurman, the White House adviser, attributed some of
>the new energy to the emotion of visits to Africa by
>executive and legislative delegations in 1999.
>Gillespie, who acknowledges past skepticism on the
>severity of AIDS, said the calamity's impact on policy
>is inevitably greater than any hypothetical prediction.
>"In a policy position you learn a healthy skepticism
>for all the [projected] numbers," he said in an
>interview. "If you look at all the studies on [ideas
>for] reducing mortality and you add them all up, you've
>saved every life about three times over."<P>
>
>In the wealthy nations, many AIDS authorities suspect,
>the place of Africa at the center of the pandemic
>accentuated such skepticism or muffled the urgency of
>the response. In and out of Africa, it is seldom
>possible to discuss the matter without touching the
>question of race.<P>
>
>James Love, an authority on global drug markets,
>imagines a " '30 million white people' test" by which
>to measure the urgency of the wealthy nations. "You'd
>move, kind of like it was an emergency," he said.<P>
>
>Piot, the UNAIDS chief, said he has no doubt that "if
>this would have happened in the Balkans, or in Eastern
>Europe, or in Mexico, with white people, the reaction
>would have been different."<P>
>
>Sometimes the analysis is more conspiratorial. Last
>month, the International Labor Organization recruited
>Namibian President Sam Nujoma to unveil new measures to
>combat AIDS. The official record reflects a sober
>package of proposals prepared for Nujoma's June 8
>speech in Geneva. In fact, Nujoma angrily set the sheaf
>of papers down on the lectern without reading them.<P>
>
>What he actually said was this: "We in Namibia are the
>sufferers of this dreadful disease. It is also a
>historical fact that HIV/AIDS is a man-made disease. It
>is not natural. States that produced chemical weapons
>to kill other nations are known, they are probably
>represented here, they know themselves, too." Those
>countries unleashed the plague, he said, and they
>should cure it.<P>
>
>A Magic Bullet?<P>
>
>Global AIDS has reached a moment of unaccustomed
>prominence. Heads of state speak its name, and
>Piot--once unable to publish his Kinshasa results in
>professional journals--is now the subject of admiring
>notice in the pages of Vanity Fair. Pharmaceutical
>companies are deep in talks with African governments
>over discounts they may offer for HIV drugs.<P>
>
>The Clinton administration, which added $200 million to
>global AIDS prevention last year, is preparing
>proposals to add another $250 million, according to
>knowledgeable officials. Half a dozen proposals in
>Congress, representing Republicans and Democrats both,
>contemplate still higher spending. President Clinton
>plans to press allies at the G-7 summit of
>industrialized countries later this month to give major
>new emphasis to the pandemic as well.<P>
>
>Will the belated awakening bring real change? The
>answer, according to many experts on the disease,
>depends in part on abandonment of the quest for what
>Merson--now dean of public health at Yale--calls "a
>magic bullet."<P>
>
>Governments in Africa and elsewhere repeatedly have
>pinned their hopes on a technical fix for AIDS--a
>vaccine, or a natural plateau in infections, or an
>effective pharmaceutical cure--that would enable them
>to sidestep the more painful measures that authorities
>say are required.<P>
>
>But among AIDS experts there is a near-consensus that
>combating the disease requires governments to interpose
>themselves into controversies of sex, injected drugs
>and other taboos. It also requires costly change in
>economies and national cultures.<P>
>
>"We know what works," said Piot, who has spelled out
>the program in increasing detail since taking his
>UNAIDS post in 1996. "We know what to do."<P>
>
>The job is first of all for Africans to undertake, said
>Malegapuru Makgoba, president of South Africa's Medical
>Research Council. "I am tired of hearing that the
>international community is slow when governments on
>this continent are irresponsible," he said. Nearly
>every authority believes, even so, that those
>governments will need outside help.<P>
>
>In some respects, experts say, addressing AIDS demands
>a new set of considerations in the effort to build
>modern economies. Pressures from international lenders
>to forge the institutions of an export-driven market,
>for example, have sometimes led to cuts in social
>spending in Africa and to patterns of urban migration
>that spread the disease.<P>
>
>"Why are there still truck routes from Durban to
>Johannesburg, instead of breaking them up?" demanded
>Paul Pronick, a Canadian volunteer physician in South
>Africa's rural Northern Province. "Why are we still
>allowing three or four thousand men to live in barracks
>[around mining sites] with no social life?"<P>
>
>A multibillion-dollar prevention program in sub-Saharan
>Africa, according to plans now under preparation by the
>White House, World Bank, USAID and UNAIDS, would
>include hundreds of millions of dollars in
>youth-focused education, intensive counseling of sex
>workers, provision and "social marketing" of condoms
>and much more aggressive treatment of lesser venereal
>diseases, which speed transmission of AIDS. Other
>programs would provide low-cost drugs to slow
>transmission of the virus in childbirth, blood testing
>and improvements in blood bank quality controls.<P>
>
>Each of these methods has been validated in test
>programs, and most of them are features of Africa's two
>exceptional successes: Uganda and Senegal.<P>
>
>But until recently, none of this was contemplated on a
>scale large enough to make a difference--not by most
>African governments and outside donors, many of whom
>persisted in hoping for a technological fix.<P>
>
>Gillespie, the USAID official, summarized American
>policy in a memorandum in December 1998: to "buy time
>until a vaccine or some other yet-to-be-identified tool
>becomes available." Frank Dobson, the British secretary
>of state for health, expressed similar views the same
>year. The hope dates back even farther. AIDS research
>pioneer Robert Gallo and HHS Secretary Margaret Heckler
>spoke optimistically of an AIDS vaccine within two
>years. That was April 23, 1984.<P>
>
>A vaccine would, of course, make a difference. But many
>authorities still regard it as a mirage, even if the
>science and mass production problems were solved. Few
>countries in the developing world have the records,
>roads, facilities and trained personnel to locate, much
>less inoculate, all their citizens. That kind of
>infrastructure does not spring up quickly, even with
>money.<P>
>
>By way of analogy, Daniel Tarantola at the WHO cites a
>massive effort since the 1970s to inoculate every child
>against such common killers as measles. "Immunization
>efforts have been going on 20 years and you still have
>countries with 40 or 50 percent coverage," he said.<P>
>
>The world's great vaccination triumph is smallpox.
>Edward Jenner, the 18th century Gloucestershire
>physician, demonstrated in 1796 that a weakened strain
>of the virus extracted from cows would build immunity
>in humans. He published his findings two years
>later.<P>
>
>In time the smallpox vaccine came into wide use, and a
>mass killer was expunged from humankind. It was 1979
>when the world reached that milestone, 183 years after
>Jenner solved the problem in his lab.<P>
>
>Staff researcher Robert Thomason contributed to this
>report.<P>
>
>About This Series<P>
>
>A decade after an unprecedented health crisis was
>forecast for Africa, AIDS has killed millions of
>Africans and threatens to kill tens of millions more.
>Meanwhile, from policymakers in the world's richest
>capitals to leaders of the most affected countries, the
>response to the disease has been marked largely by
>inaction, indifference and self-interest. This series
>examines the decisions--and missed opportunities--at
>the international, national and community level that
>have shaped the advance of AIDS across the continent
>most affected by the disease.<P>
>
>A Difference of 15 Years<P>
>
>In 16 countries, all in sub-Saharan Africa, more than
>one in 10 adults is infected with the HIV virus. In
>seven of those nations, one in five carries the deadly
>virus.<P>
>
>The worst affected<P>
>
>Adult infection rate as of December 1999<P>
>Botswana 35.8%<P>
>Swaziland 25.3<P>
>Zimbabwe 25.1<P>
>Lesotho 23.6<P>
>Zambia 20.0<P>
>S. Africa 19.9<P>
>Namibia 19.5<P>
>
>Malawi 16.0<P>
>Kenya 14.0<P>
>Cent. Afr. Rep. 13.8<P>
>
>Infection rates elsewhere for comparison:<P>
>
>U.S. 0.61%<P>
>India 0.70<P>
>Thailand 2.15<P>
>Brazil 0.57<P>
>Nigeria<P>
>
>Population 109 million (50.7 million adults)<P>
>
>2.7 million people infected (5.06 percent of adults)<P>
>
>Most West African nations show relatively low infection
>rates, but experts worry that the virus could spread
>rapidly among Nigeria's huge population. Some urban
>areas show much higher infection rates.<P>
>
>Zambia<P>
>Population 9 million (4.1 million adults)<P>
>870,000 people infected (19.95 percent of adults)<P>
>There are early signs that Zambia is following Uganda
>in fighting the epidemic. The HIV rate among pregnant
>15- to 19-year-olds in Lusaka, the capital, has dropped
>by almost half from 1994.<P>
>
>Botswana<P>
>Population 1.6 million (775,000 adults)<P>
>290,000 people infected (35.8 percent of adults)<P>
>The country has a well-developed road system and is a
>hub for truckers from across southern Africa. This high
>mobility of people facilitates the spread of HIV.
>Although relatively prosperous, Botswana has spent
>little on anti-HIV programs.<P>
>
>South Africa<P>
>Population 39.8 million (20.6 million adults)<P>
>4.2 million people infected (19.94 percent of
>adults)<P>
>More people are infected with HIV in South Africa than
>in any other nation, and the infection rate is among
>the fastest growing in the world. Anti-AIDS programs
>are mired in controversy.<P>
>
>Uganda Population 21.2 million (9.2 million adults)<P>
>820,000 people infected (8.3 percent of adults)<P>
>Uganda was the first African government to respond
>aggressively to the danger of AIDS. A prevention drive
>cut the infection rate from 14 percent in 1990.<P>
>
>SOURCE: UNAIDS<P>
>
>Waking Up to Devastation<P>
>
>U.N. epidemiologists predicted in 1991 that by the end
>of the decade, 9 million people in sub-Saharan Africa
>would carry the HIV virus, which causes AIDS. Current
>figures are 21/2 times that high. Unless a large-scale
>anti-HIV/AIDS campaign is launched, experts fear that
>50 million people worldwide could be living with HIV by
>2005. Industrialized donor countries contributed about
>$350 million last year to fight AIDS overseas, half of
>it U.S. money.<P>
>
>Cost of treatment<P>
>
>The U.N. AIDS office has estimated that at least $1
>billion is needed to establish an effective
>HIV-fighting program in sub-Saharan Africa. U.N.
>epidemiologists estimate that it would cost between
>$1,400 and $4,200 a year per patient in sub-Saharan
>Africa to treat the infection and the disease
>effectively with antiretroviral drugs.<P>
>
>Funds available<P>
>
>In 1997, the United States spent $7 billion in
>development aid overseas, with $121 million of it going
>toward fighting AIDS. Only last year were appreciably
>more funds allocated. U.S. funds to fight the epidemic
>now make up about half of all donor nations'
>contributions.<P>
>
>NOTE: All infection rates are based on estimates. The
>vast majority of sub-Saharan Africans are never tested
>for HIV and do not know if they carry the virus. The
>only basis available to UNAIDS are tests from prenatal
>clinics and tests administered to people in high-risk
>categories, such as sex workers.<P>
>
>SOURCES: UNAIDS, USAID, private foundations<P>
>
>AIDS in Numbers<P>
>
>Women<P>
>
>In sub-Saharan Africa, a higher proportion of women
>than men live with HIV infection or suffer from AIDS.
>The infection rate is particularly high among
>girls.*<P>
>
>Number of people living with HIV/AIDS, in millions<P>
>
>Women Men Children under 15<P>
>Sub-Saharan Africa 12.9 10.6 1.0<P>
>Total: 24.5 million<P>
>Worldwide 15.7 17.3 1.3<P>
>Total: 34.3 million<P>
>
>* Male to female infection is more likely than female
>to male, particularly among girls who are physically
>not fully developed. Also, young girls often have
>sexual relations with men in their 20s and 30s who
>often already are infected.<P>
>
>Deaths<P>
>
>5,500 people die of AIDS in sub-Saharan Africa every
>day -- the equivalent of almost half the student body
>of Howard University or American University. By 2010,
>about 13,000 people will die daily of AIDS.<P>
>
>Sub-Saharan Africa Elsewhere<P>
>
>People who have died since the start of the epidemic:
>11.5 million 7.3 million<P>
>
>18.8 million total<P>
>
>People now living<P>
>
>with HIV/AIDS: 24.5 million 9.8 million<P>
>
>34.3 million total<P>
>
>Orphans<P>
>
>AIDS has created 13.2 million orphans, most of them in
>sub-Saharan Africa. By 2010, UNAIDS estimates, there
>may be 42 million orphans -- the number of children in
>the United States living east of the Mississippi.<P>
>
>Number of orphans*<P>
>
>12.1 million in sub-Saharan Africa<P>
>
>1.1 million in rest of world<P>
>
>* Children who have lost their mother or both parents
>to AIDS<P>
>
>Life expectancy<P>
>
>Life expectancy, already cut by AIDS in many
>sub-Saharan countries, is expected to fall further by
>2010.<P>
>
>SOURCES: UNAIDS, staff reports<P>
>
>The Impact of AIDS<P>
>
>Population structure<P>
>
>HIV will change the composition of populations in
>countries with high infection rates. AIDS deaths will
>radically shrink the proportion of women older than
>their early 20s and men older than their early 30s.<P>
>
>Labor Cost<P>
>
>The cost to government and private employers of the
>labor force is rising because of higher insurance
>premiums and costs of training new workers, faster
>turnover and absenteeism due to HIV and AIDS.<P>
>
>Distribution of the added cost in Kenya, in percent<P>
>
>52% Absenteeism due to HIV/AIDS<P>
>
>23% Labor cost*<P>
>
>13% Absenteeism due to funeral attendance, burial
>costs<P>
>
>12% Health care<P>
>
>*Includes extra training, recruitment costs,
>productivity loss of new employees and other labor
>turnover costs<P>
>
>Work Force<P>
>
>Some companies in sub-Saharan Africa have begun to hire
>two or three employees for the same position, fearing
>that workers in key positions may be lost to AIDS. By
>2020, the labor force in some of those countries will
>have shrunk by more than 20 percent because of AIDS.<P>
>
>Estimated percentage of labor force lost to AIDS in
>2020<P>
>
>based on current infection projections<P>
>
>Namibia 22%<P>
>Botswana 21<P>
>Zimbabwe 21<P>
>Mozambique 19<P>
>
>S. Africa 17<P>
>Kenya 15<P>
>Malawi 13<P>
>Uganda 12<P>
>
>SOURCES: U.S. Census Bureau's World Population Profile,
>UNAIDS, International Labor Organization, U.S. Census
>Bureau's World Population Profile 2000<P>
>
>
><HTML><HEAD><TITLE>Free of Apartheid, Divided by Disease</TITLE>
></HEAD><BODY>
>
><B>Free of Apartheid, Divided by Disease</B>
>By Jon Jeter<BR>
>Washington Post Foreign Service<BR>
>Thursday, July 6, 2000; A01
>
>JOHANNESBURG; The last days of apartheid were closing in in 1993
>when South Africa's government-in-waiting summoned nearly 50
>public health experts to a conference hall just north of here. The
>African National Congress, soon to turn from rebels to ruling
>party, wanted help devising a strategy to fight an advancing AIDS
>epidemic.<P>
>
>Expectations were soaring. Certainly, money was tight and there
>was much to be done in the top-down transformation from
>white-minority rule that would follow South Africa's first
>democratic elections in a few months. But if any developing
>country could provide a model for standing up to the epidemic,
>surely it was this one, with its industrialized economy and
>educated, democratic, socially conscious leaders waiting in the
>wings.<P>
>
>Tensions surfaced at the inaugural meeting of the AIDS panel,
>however. Nkosazana Zuma, whom President Nelson Mandela would
>appoint South Africa's first black health minister, insisted on
>steering discussion away from economic factors that helped spread
>AIDS but were also central to the ANC's higher priority of
>creating jobs and investment. When Helen Schneider and Liz Floyd,
>two whites who had supported the black majority's long liberation
>struggle, repeatedly pressed for an AIDS policy that addressed the
>role of migrant labor, Zuma finally turned to a colleague in
>exasperation.<P>
>
>"White people," she complained, "just don't understand the
>issues."<P>
>
>Six years into the ANC's imperfect but breathtaking overhaul of
>South Africa, the government's failure to cope with AIDS
>jeopardizes practically everything the country has achieved since
>the end of oppressive white rule. More people are infected with
>HIV in South Africa than in any other country--one in five adults
>in a population of about 41 million. AIDS threatens to slow social
>change and undo economic development with the staggering costs of
>caring for the sick, the dying and those they leave behind.<P>
>
>Decoding South Africa's ineffectual official response to its most
>dire public health crisis is complicated. But if anything connects
>the series of political missteps, mishaps and misunderstandings
>culminating with President Thabo Mbeki's recent blunt questioning
>of long-accepted scientific conclusions about the nature of AIDS
>and its treatment, it is the raw and deep wound left by the racial
>caste system of apartheid.<P>
>
>Confronted with forecasts of a cataclysmic plague at precisely the
>same euphoric moment that their epic struggle was on the verge of
>victory, the ANC approached AIDS at first with a mixture of
>denial, resentment and tentativeness. Both high expectations and
>skepticism among some in the ability of blacks to govern
>encouraged the ruling party to embrace quick fixes against the
>disease. When these measures failed, the leaders bristled at the
>ensuing criticism, alienating even their closest allies.<P>
>
>After decades of seeing friends and relatives jailed, poisoned and
>even sterilized by whites, the ANC shut clinics that could have
>been useful in treating and counseling patients infected with HIV,
>largely because the facilities were heavily staffed by white
>doctors, according to people involved in AIDS policy. After
>negotiating an uneasy coexistence with the white minority, the new
>leaders' initial efforts to address the epidemic were slowed and
>even sabotaged by white civil servants inherited from the
>apartheid era.<P>
>
>And when medical experts warned them that a homegrown vaccine was
>worthless, leaders from the president down plowed quixotically
>ahead. Those involved in the effort say they were convinced that
>they could redeem the indignities, insults and stereotypes that
>Africans had endured at the hands of whites by discovering a
>miracle vaccine for a disease that not even the West could
>cure.<P>
>
>"I don't think anyone can give a simple explanation for why our
>AIDS program has failed," said Morna Cornell, director of the AIDS
>Consortium, a nonprofit counseling project. "But the race issue is
>huge. It's like we eliminated apartheid but it left behind this
>huge wall that none of us knew how to tear down or get around."<P>
>
>The irony is that, so far, the African country best prepared in
>material and political terms to provide hope against the epidemic
>has also proven among the least capable of overcoming economic
>inequality, bitter distrust and social barriers that fuel the
>spread of HIV and AIDS.<P>
>
>"AIDS is a devious disease," said Ralph Mgijima, an ANC provincial
>health officer. "It thrives on divisiveness."<P>
>
>For many of the 4 million South Africans with HIV and AIDS, the
>overwhelming majority of them blacks who have waited much of their
>lives for a government that represents them, the situation holds a
>bitter, more personal irony.<P>
>
>"It is very hard living your life with HIV," said Florence
>Ngobele, who was diagnosed with the virus that causes AIDS six
>years ago and lost her daughter to the disease. "And you almost
>feel like the government is trying to tell you: If you have HIV,
>we have nothing for you. We can't help you. [The government] has
>done a lot for this country but sometimes you catch yourself
>wondering: Did they free us just to watch us die?"<P>
>
>Stumbling From the Gate <P>
>
>With thousands of exiles living in Zambia, Tanzania, Uganda and
>other African countries during apartheid, the African National
>Congress--the biggest and most powerful anti-apartheid
>organization--recognized long before 1994 that a health crisis was
>in the making.<P>
>
>"By 1989, we could see AIDS all around us in the countries where
>we were in exile and we were already seeing some HIV-positive
>comrades," said Mgijima, the ANC health officer, who was based at
>the time in Lusaka, Zambia.<P>
>
>In 1990, shortly after then-President F.W. DeKlerk released
>Mandela from prison and rescinded the ban on outlawed political
>movements, the ANC convened an AIDS conference in Mozambique's
>capital, Maputo. Chris Hani, who headed the ANC's guerrilla
>forces, Umkhonto we Sizwe, or Spear of the Nation, and whose
>popularity at the time was arguably surpassed only by the iconic
>Mandela, spoke with great urgency.<P>
>
>"We cannot afford to allow the AIDS epidemic to ruin the
>realization of our dreams," said Hani, who was assassinated by
>white supremacists in 1993.<P>
>
>But the ANC's return to open politics coincided with a seismic
>shift in the spread of HIV. Largely isolated to white, gay men
>when it first appeared in the country in the early 1980s, the
>virus had by 1990 begun infecting primarily black
>heterosexuals.<P>
>
>"It was doubly stigmatized," said Mark Gevisser, a South African
>journalist who is writing a biography of Mbeki. "It went from
>being the 'Gay Plague' to the 'Black Death' and it really
>reinforced the stereotype of the supersexualized, irresponsible
>black male. This is the stigma that the exiles came home to."<P>
>
>As the ANC and then-ruling National Party engaged in tense
>negotiations for a transition to majority rule, the apartheid
>regime used fear of AIDS to undermine the popularity of their
>adversary. Fliers with crude depictions of black men began to
>appear in the black townships, warning that virus-carrying exiles
>were importing HIV to the country.<P>
>
>"That definitely put us on the defensive," said Smuts Ngonyama, an
>ANC spokesman. "We, on the one hand, understood that this was a
>disease that we needed to deal with. But we also resented the
>National Party's demonization of us as promiscuous . . . and
>terrorists bringing death and disease home to our people. They
>were aggressively selling this stigma so that we couldn't stand on
>the moral high ground. People would say to us: 'You know, I'm just
>not sure about the ANC.' "<P>
>
>The advisory panel assembled by the ANC in 1993 and headed by Zuma
>devised an AIDS plan for the new government. More wish list than
>blueprint, it prescribed $64 million worth of education programs,
>mass media campaign, free condoms and support programs for
>patients with HIV. It recommended creation of a national AIDS
>commission, modeled in part on an approach in Uganda that was then
>beginning to be hailed as a success. <P>
>
>The panel proposed running the anti-AIDS effort from the
>president's office to give it a high profile and bureaucratic
>authority with government ministries such as the labor department,
>which would be more likely to accept direction on strategies in
>the workplace for dealing with HIV.<P>
>
>Mandela's first budget included $15 million for a national AIDS
>campaign, rather than the $64 million proposed by the panel. And
>he installed the initiative in the health department, headed by a
>mid-level bureaucrat rather than a deputy minister, eventually
>limiting the agency's scope and authority.<P>
>
>There were more immediate obstacles for the campaign in the months
>after the 1994 elections. As part of an agreement with the
>National Party, the ANC had promised not to fire white civil
>servants from the old regime. The apartheid government's HIV
>program was virtually nonexistent and most bureaucrats were
>neither prepared nor helpful in developing a national AIDS
>strategy.<P>
>
>"None of the staff I inherited even knew how HIV was transmitted
>or the methods of prevention," said Quarraisha Abdool Karim, South
>Africa's first national AIDS director. "That's 12 people with whom
>I had to start from scratch with before I could even begin to
>implement a program."<P>
>
>Other administrators said they were met with hostility from
>bureaucrats. Floyd, the director of the AIDS program for Pretoria
>and Johannesburg, said that she wasn't assigned an office for
>nearly a year by the building manager. She bounced around through
>six temporary offices and when she was finally provided working
>space, it was hardly bigger than a closet.<P>
>
>"We were working with people who could care less if black people
>died from AIDS. I refused to bring people into the office
>[because] I was afraid they wouldn't take AIDS seriously if they
>saw the space I had been allocated," she said.<P>
>
>Said Glenda Gray, a senior researcher in the maternity ward at
>Chris Hani Baragwanath Hospital in Soweto, the country's biggest
>medical center: "I don't know how you get a national AIDS program
>to work when you've inherited a civil service that you don't trust
>and that doesn't trust you and wants to stick it to you at every
>turn."<P>
>
>The one salvageable component of the apartheid regime's HIV
>efforts were 18 AIDS Training, Information and Counseling Centers,
>known by their acronym as ATICCs. Far from perfect, the clinics
>were located mostly in urban neighborhoods not easily accessible
>to blacks who lived in segregated townships or in the countryside.
>Still, the centers provided valuable testing and counseling HIV
>services for patients as well as much-needed training for
>inexperienced staff, many experts believed.<P>
>
>But the popular perception of the ATICCs, shared by many in the
>ANC, was that they were staffed mainly by gay and liberal
>whites.<P>
>
>"You had people running the ATICCs set and we were concerned about
>that," said the ANC's Mgijima. "Could they communicate with
>Africans? It's not that they weren't well meaning, but a lot of
>blacks here are isolated from information and remember the
>apartheid era's sterilization programs. So if someone from the
>ATICCs handed him a condom he's likely to think that this is just
>an invention of that person meant to depopulate African
>communities. The ATICCs became irrelevant in our minds."<P>
>
>The clinics' HIV programs were marginalized and subsequently
>abandoned in many communities. "The ATICCs . . . could have been
>developed and used as a base to build on," said Mary Crewe,
>director for the Center for the Study of AIDS at the University of
>Pretoria and a former ATICCs worker at Johannesburg's Esselin
>Street Health Center. "Now instead of having more HIV services we
>have less."<P>
>
>Tension Over Spending <P>
>
>Within a year after the 1994 elections, the number of South
>African adults infected with HIV had risen to one in 10--up from
>about .76 percent in 1990. Immigration across borders that had
>been closed by the apartheid regime was ending isolation that had
>spared South Africa from some of the soaring infection rates of
>neighboring countries.<P>
>
>Overwhelmingly endorsed by voters, the ANC was now feeling the
>pressure to deliver housing, jobs and health care to an
>impoverished black majority. The party was also under greater
>scrutiny from major newspapers, most staffed and owned by whites,
>which supported democracy but were unsparing in criticizing the
>government.<P>
>
>Without consulting her panel of independent advisers, Zuma
>circumvented state contracting procedures and spent $3
>million--roughly a fifth of the department's entire annual
>anti-AIDS budget--to produce an AIDS awareness play that
>capitalized on the popularity of "Sarafina," the musical about
>poor children growing up in a South African township that became a
>Broadway production and Hollywood movie.<P>
>
>When news of the contract was leaked, newspaper columnists and
>cartoonists had a field day. Activists panned the play's anti-AIDS
>message as simplistic and questioned whether it was a good use of
>limited funds.<P>
>
>With the support of her two mentors, Mandela and then-Deputy
>President Mbeki, Zuma wondered aloud if her critics would have
>been so upset if the playwright had been white instead of black.
>The contract was subsequently canceled and Mandela later
>acknowledged that "Sarafina II" was one of the biggest mistakes of
>his term. But the damage was done.<P>
>
>" 'Sarafina' was the biggest mistake . . . because it made AIDS
>into a joke," Cornell said. "And it put [AIDS activists] in an
>adversarial relationship with Zuma that we never quite managed to
>mend. From that point on, if you criticized the government you
>were dismissed as unpatriotic, unsupportive and generally racist.
>I've always felt that as a white woman I had to really watch what
>I said."<P>
>
>Less than a year later, Zuma unexpectedly announced her intention
>to require people with HIV to make their status public. Pushing
>the disease into the sunlight, she argued, would lift the cloak of
>secrecy that abetted its transmission from one sexual partner to
>another, as well as diminish the stigma surrounding HIV. The term
>was still taboo in parts of South Africa, and fear had led mobs to
>attack people with HIV.<P>
>
>Cornell and other activists objected. Forcing someone to disclose
>a diagnosis could lead to further isolation, anxiety and even
>depression, all of which can accelerate the onset of full-blown
>AIDS. With a flimsy health care system, notification was also
>impractical. And lastly, there was the issue of fairness.<P>
>
>"How can the government make someone publicly reveal their HIV
>status when they have nothing to offer them in return?" asked
>Cornell.<P>
>
>When reporters questioned Olive Shisana, the director general of
>the health department, whether disclosure requirements were a
>violation of civil rights, she answered that confidentiality was a
>"Western, gay" preoccupation.<P>
>
>"There is in this country a long history of whites telling us what
>do with our bodies," said Zweli Mkhize, the ANC's health minister
>in KwaZulu-Natal province, "and you'll find some resentment of
>that still. There has always been this debate about Africans
>determining what is right for Africans, not whites."<P>
>
>When the AIDS advisory panel requested a meeting with Zuma to
>discuss confidentiality, health officials assured them that a
>meeting would be arranged. While awaiting word from Zuma's office,
>the panel chair received a letter from Shisana in late 1997. The
>panel had been disbanded.<P>
>
>Shame and Redemption <P>
>
>The ANC's policy of pushing AIDS into the open did not extend to
>its top officials and policymakers. By 1997, a clear pattern had
>emerged. Other than responding to criticism or journalists'
>questions, few cabinet ministers other than Zuma ever mentioned
>the virus in public.<P>
>
>Even the revered Mandela made no public mention of AIDS until he
>delivered a speech in late 1997 to the World Health Organization,
>and that was in Switzerland. His first public remarks on the
>subject in South Africa were not spoken until 1998, more than
>three years into his presidency.<P>
>
>"Indeed, measured minute by minute, during his presidency, Mandela
>probably spent more time with the Spice Girls and Michael Jackson
>than he did raising the AIDS issue with the South African public,"
>wrote South African journalist and researcher Hein Marais.<P>
>
>Clearly, government officials had a lot on their plate; they had a
>country to build. But some believed that the silence reflected the
>ANC's ambivalence about AIDS. On one hand, the party clearly
>recognized its impact on the population. On the other, there was a
>sense of shame rooted in Africa's conservative, male-dominated
>culture in which talking about sex and wearing condoms were
>discouraged.<P>
>
>"For all his greatness," said Cornell, "Mandela is still a kindly,
>respectful, 83-year-old African male. Talking about sex in public
>cannot come easily for him."<P>
>
>That silence, many AIDS activists feared, fueled suspicions by
>some rural blacks that AIDS didn't really exist and was a ruse to
>depopulate African communities through condom use, AIDS activists
>say.<P>
>
>"There is such denial in this country," said Edwin Cameron, a High
>Court judge who is the country's highest ranking public official
>to acknowledge that he has AIDS. "If you believe that
>interventions by a political leader can make a difference then you
>have to believe that one of the most extraordinary icons of this
>century could have convinced young men and women to wear
>condoms."<P>
>
>The government today points to successes in AIDS prevention: It
>has distributed 140 million condoms, trained more than 10,000
>teachers to conduct AIDS education, and improved access to health
>care. A nationwide publicity campaign has hoisted arresting
>billboards across Johannesburg, Cape Town and Durban advocating
>safe sex.<P>
>
>Still, while 85 percent of South Africans in a recent poll said
>they now know how HIV is transmitted, only 10 percent said they
>used a condom in their last sexual encounter.<P>
>
>Drug Discredited <P>
>
>In January 1997, Zuma invited to a cabinet meeting three Pretoria
>researchers who said they had discovered a drug that could cure
>AIDS. The scientists had used skin patches of a compound called
>Virodene P058 on HIV-infected volunteers and reported the
>preliminary findings to Zuma. She appealed to the cabinet for
>funding and tried to speed the drug's approval with the Medicines
>Control Council, the equivalent of the U.S. Food and Drug
>Administration.<P>
>
>The cabinet, which gave the researchers a standing ovation at the
>end of their 90-minute presentation, believed the discovery would
>validate South Africa's black majority in much the same way that
>Christiaan Barnard's first successful heart transplant in 1968
>affirmed apartheid South Africa to the world, said Salim Karim,
>director of HIV prevention and vaccine research for the Medical
>Research Council.<P>
>
>Newspapers championed the discovery of Virodene as a miracle cure.
>But Peter Folb, the Medicines Control Council director, said the
>researchers had not followed accepted practices and further
>investigation was needed before the drug could be approved. Both
>Zuma and Mbeki, still deputy president, pressured Folb to approve
>the drug.<P>
>
>When the opposition Democratic Party criticized the ANC's
>endorsement of Virodene, Zuma responded, "The DP hates ANC
>supporters. If they had their way we would all die of AIDS."<P>
>
>Virodene was soon discredited as an effective treatment, and was
>judged to be harmful after it was revealed that its active agent
>was an industrial solvent. Quarraisha Karim, the first director of
>South Africa's national AIDS program, said that the government's
>policy on the drug was driven entirely by politicians without
>consulting either herself or any advisers with technical
>experience.<P>
>
>"There was this sense that this drug would be the thing that
>offset the perception . . . of Africans as substandard and less
>than capable," Karim said. "All eyes were upon [the ANC] and the
>expectations were very high and they were really trying to find
>their feet but they didn't want to exercise caution," she said.
>"This was driven by this need to show the world: 'Yes, Africans
>can do this. We can do this. Virodene became our redemption.' "<P>
>
>Folb, who is white but is a member of the ANC, recalled one late
>night conversation with Zuma, who was pressing him to approve
>Virodene despite his concerns that it hadn't been adequately
>tested. Folb politely but firmly repeated his refusal. Finally, a
>frustrated Zuma blurted out: "You're ANC. Why won't you back me on
>this?"<P>
>
>Model of What Went Wrong <P>
>
>In 1990, the prevalence of HIV infection in South Africa and
>Thailand were both less than 1 percent. Today, Thailand's rate is
>2.15 percent; South Africa's is 19.94 percent.<P>
>
>As an international AIDS conference opens this weekend in Durban,
>on South Africa's Indian Ocean coast, the country is a model not
>of progress against the disease, but of things gone wrong.
>Mbeki--described by friends and even critics as among the smartest
>and most capable leaders in the developing world--has become
>better known internationally for his skepticism about conventional
>AIDS treatments than for any other reason.<P>
>
>Some see parallels between the Virodene episode and Mbeki's
>staunch refusal to support even low-cost antiretroviral drugs for
>pregnant women, despite research indicating that the medicine can
>reduce the transmission of HIV from mother to child by as much as
>half. In championing an African solution, Mbeki has questioned
>whether the drugs are toxic, and whether Western remedies apply in
>sub-Saharan Africa. <P>
>
>There are no such questions in the maternity ward at Baragwanath
>Hospital in Soweto where 40 percent of the 600 babies delivered
>each month carry the virus. "I just want to know," said one gaunt
>woman, who is nine months pregnant and infected with HIV, "what
>kind of treatment is available that might help us and our children
>live longer." <P>
>
>The hospital's donated supply of AZT will last only a few months
>more. Then administrators will have only counseling to offer
>pregnant women, said Florence Ngobele, who heads a support group
>of expectant mothers who have tested positive for HIV.<P>
>
>The irony, she said, "is that this is what I would have expected
>from the apartheid government, not the new South Africa. They have
>broken our hearts." <P>
>
>HIV Facts <P>
>
>While the HIV infection rate was less than one percent in South
>Africa and Thailand in 1990, South Africa's has risen dramatically
>and is still growing . . .<P>
>
>Estimated HIV infection rate <P>
>
>In percent of adult population<P>
><P>
>1999<P>
>South Africa 19.94%<P>
>Thailand 2.15%<P>
><P>
>. . . One indication that the epidemic is still growing is the
>increase of women coming to pre-natal clinics and testing positive
>for HIV. It means their babies will likely be infected, too.<P>
><P>
>AIDs has become the leading cause of death in sub-Saharan Africa,
>and 1,700 people are newly infected in South Africa alone every
>day.<P>
><P>
>World<P>
>1. Heart disease: 12.7%<P>
>2. Cerebrovascular disease*: 9.9<P>
>3. Acute lower respiratory infections: 7.1<P>
>4. HIV/AIDS: 4.8<P>
>5. Chronic obstructive pulmonary disease: 4.8<P>
>Sub-Saharan Africa<P>
>1. HIV/AIDS: 20.6%<P>
>2. Acute lower respiratory infections: 7.1<P>
>3. Malaria: 9.1<P>
>4. Diarrheal diseases: 7.3<P>
>5. Perinatal conditions: 5.9<P>
><P>
>*For example: stroke<P>
><P>
>SOURCE: UNAIDS, Center for the Study of AIDS, University of
>Pretoria
></BODY></HTML>
>
>
><HTML><HEAD><TITLE>Disease Spread Faster Than the
>Word</TITLE></HEAD><BODY>
>
><B>Disease Spread Faster Than the Word</B>
>By Karl Vick<BR>
>Washington Post Foreign Service<BR>
>Friday, July 7, 2000; A01
>
>Last of three articles<p>
>
>MASOGO, Kenya; Andrecus Miruka was a son of the lake. Born in his
>father's house not 20 miles from Lake Victoria, he spent the years
>before the plague aboard a steamship, ferrying freight across the
>heart of Africa and passengers from Kenya to Tanzania to Uganda
>and back. There were women among the men, but if at times the
>decks of the MV Victoria thrummed with more than the power of
>diesel, it still meant life.<p>
>
>By the time the ship's pilot retired to the town of Masogo in
>1992, the virus was already there. But Miruka, who relishes his
>role of protector--his black cane holds a concealed saber--saw no
>threat. It was a routine matter when a cousin named Hezron fell
>ill, his body erupting with boils and diarrhea. Miruka paid an
>elder of his tribe, the Luo, to conduct a traditional diagnosis
>involving thrown shells.<p>
>
>When the "Luo X-ray" came up blank, Hezron was carried to the
>provincial hospital. The doctors diagnosed one thing but told the
>family another--"typhoid," they said--before sending Hezron home
>to die. In 1997, when his widow fell ill, the real diagnosis was
>finally shared: AIDS.<p>
>
>It was a word Miruka had first heard in 1990. But only now, most
>of a decade later, could he bind it to the suffering he had been
>seeing in the huts around his birthplace every year since. And
>with understanding, there was hope for change.<p>
>
>"For me, I learned about it and immediately set about mobilizing
>the community," said Miruka, 63. "I didn't keep quiet about that
>message."<p>
>
>In wealthier parts of the world, information is an industry, a
>commodity available with such speed and abundance that the word
>defines the age. But in sub-Saharan Africa, where 71 percent of
>the world's HIV-infected population lives and which has
>contributed 61 percent of the lives sacrificed to AIDS,
>information provides more than context for the disease. In places
>without money or medicine to fight back--almost all of Africa--it
>is the whole story.<p>
>
>In Masogo, information that might save lives came to local leaders
>almost 20 years into the epidemic. From the town's dilapidated
>health center, useful knowledge about AIDS took four more years to
>travel three miles down a gravel road worn smooth on the shoulder
>by the constant traffic of bicycle taxis.<p>
>
>But by then, an estimated 30 percent of the local population had
>HIV, the virus that causes AIDS. The most recent U.N. statistics
>predict that, across Kenya, half of the girls who turn 15 this
>year will be infected with the virus during their lifetimes. Here
>among the Luo, the second largest of Kenya's tribes, that
>projection reaches 70 percent.<p>
>
>How those most at risk for AIDS were left in the dark for so long
>is not a question that preoccupies the people here. They say
>without apparent resentment that they are accustomed to being
>overlooked.<p>
>
>But the nature of their isolation is crucial to understanding how
>Africa has been left to die alone. When the history is written of
>what the people on the eastern shore of Lake Victoria long knew
>only as maduong, or "the big disease," the chapter on outside
>intervention--from the Kenyan government, from Western countries
>that had arrested the disease at home--will be remarkably
>short.<p>
>
>In the neglected countryside where the vast majority of Africans
>reside, the virus encountered nothing so much as opportunity. It
>fell to local communities to conjure a way to confront an enemy
>that was hard to identify, and even then could hide in a thicket
>of fear and the most intimate aspects of human behavior.<p>
>
>"We were the first ones," Miruka declared of local elders' efforts
>to raise the belated alarm. "We were the pioneers."<p>
>
>Armed with the information that might save his neighbors' lives,
>Miruka repeated it wherever people gathered: storefronts,
>schoolyards, shade trees. But by then, the best place to spread
>the word was funerals.<p>
>
>Remote From the Truth<p>
>
>The main street of Masogo is like a movie set: a line of shops,
>and nothing behind. Communities in Africa are not towns but
>strolls. One finds a cluster of huts beside a field of maize
>bordering a meadow that gives onto four more huts, all linked by
>looping footpaths, the webbing that binds the continent.<p>
>
>One day last month, Domtila Awino, wife No. 3 in Miruka's
>polygamous household, strode purposefully down the path from her
>house, across the Nyando River bridge and above the children
>bobbing naked in the brown water. Twenty minutes later she was
>seated on a wooden stool beside a man who was barely alive. Joseph
>Oloo, 38, had been ill since December. Both of his wives and three
>of their five children are already dead. "This lady," he said in a
>breathy voice, "is the only one who comes."<p>
>
>It's her job, Awino said. Last November she was trained as a
>"community health worker," sitting for a week in hotel conference
>rooms, learning the basics about the disease that killed her
>brother. The training was funded by the British government,
>through an aid agency called Futures Group International, in
>partnership with Kenya's Ministry of Health. The ministry
>maintains clinics throughout the nation of 30 million. It also has
>programs devoted to AIDS. But by all accounts, the two have not
>combined to much effect.<p>
>
>"I blame--because I'm the government--myself," said Jack Okeyo, a
>nurse at the Masogo health center. Others look up the line to
>longtime President Daniel arap Moi, who until recently paid the
>epidemic only the passing mention that was the norm among African
>leaders. Only since October, when Moi declared AIDS a "national
>disaster," has his government begun to act with anything
>resembling urgency, health workers and officials say.<p>
>
>"When you have a government that's reluctant to say we have AIDS,
>you definitely have a late start," said Richard Odindo, who
>coordinates training for Futures.<p>
>
>Left to their own devices, people applied the knowledge they had.
>Among the Luo, there was a word for persistent diarrhea, rashes
>and weight loss. "Chira" was illness brought on by breaking the
>norms that have regulated community life for centuries. A wife
>beating her husband with a cooking stick invited chira. Likewise a
>boy who, older than 15, entered his mother's bedroom.<p>
>
>But chira could be cured. Between 1988 and 1993, Helida Owiti was
>summoned 15 times to the bedsides of people diagnosed with chira.
>The wizened grandmother is one of Masogo's traditional healers,
>and she knew what to do: Pour a bit of one herb into a calabash,
>mix it with a second herb, have the patient drink it.<p>
>
>"We were not succeeding," Owiti said. "People kept dying."<p>
>
>She learned why in 1993, when towns and cities suddenly featured
>billboards bidding, "Let's Talk," the slogan for a new condom
>called Trust. It was soon on sale almost everywhere at a mere 10
>shillings (now about 7 cents) for a packet of three, a price
>heavily subsidized by Western donors. On main roads, other
>billboards advised in the local language that "AIDS is not Chira.
>AIDS is real."<p>
>
>But the message went only so far. In Masogo, it went only as far
>as people like Owiti, who lived in the town proper. She was
>visited in person by a nurse from the local health center. The
>nurse explained the symptoms of AIDS, the mode of transmission and
>the terrible prognosis. After listening to the presentation, the
>old woman put away her herbs.<p>
>
>"We just waited for people to die," she said.<p>
>
>Andrecus Miruka, living in retirement not three miles away, would
>not get the same information for more than four years. Logistics
>was one reason: The Ministry of Health--which, like health
>authorities across Africa, relies almost entirely on foreign aid
>for capital purchases--had equipped Masogo's health center with
>neither a vehicle nor anyone assigned to roam the farms where
>almost everyone lived.<p>
>
>The other reason would be whispered by Owiti, the traditional
>healer, peering from beneath a wrinkled brow with a look of
>titillated embarrassment: "I didn't want to mention sex," she
>said.<p>
>
>Almost no one does in rural Africa. Traditional societies were
>generally conservative even before missionaries arrived a century
>ago. Some AIDS experts complain that Christianity added a layer of
>shame to sex that made frank discussion that much more
>difficult.<p>
>
>"It's not that people stopped having sex, but they stopped talking
>about it," said Elizabeth Pisani, a medical demographer and
>consultant in Nairobi.<p>
>
>Certainly Miruka's eldest son, Bernard Otieno, held his peace when
>he returned from Nairobi. During five years in the capital, he had
>watched the epidemic emerge before him. During visits to the
>city's largest hospital, he heard as early as 1991 of an isolation
>ward. At the yarn factory where he worked, he saw a colleague who
>was considered a ladies' man grow thin and die a year later.<p>
>
>"That's when I realized that what I had been told at Kenyatta
>National Hospital was true," Otieno said. He feared for himself
>only until the risk factors were explained by a shop steward, in a
>welfare assembly called at the factory.<p>
>
>"The advantage of working in Nairobi was you get information quite
>fast," he said, "while in rural areas it takes quite some time for
>information to trickle down."<p>
>
>Yet when Miruka's son returned with his wife in 1993 to the family
>compound here, he kept what he had learned to himself. "It was
>difficult to tell if other people knew, because people did not
>want to talk about it," Otieno said.<p>
>
>Some of the reluctance was a matter of private fears kept private.
>Much, undoubtedly, was denial, which found a ready haven in chira,
>even though chira had never before been regarded as fatal.<p>
>
>But then what little was known about AIDS hardly invited
>association. Advertising campaigns targeted prostitutes and the
>men who used them. Ambrose Oungdha, 64, was apparently infected by
>a wife 30 years his junior, who died in 1998. The only man in
>Masogo known to have made his condition public, he said he is
>shunned by neighbors who answer his request for help with a
>question of their own: "Did we tell you to go out and get that
>disease?"<p>
>
>'We Bury Every Day'<p>
>
>In the silence, infections soared. No one knows where AIDS began,
>but researchers have traced the spread of the epidemic from Congo,
>the remote heart of Africa, eastward across the Great Lakes of
>Kivu, Tanganyika, Albert and Victoria.<p>
>
>In Kenya, the virus showed up first and most virulently on
>Victoria's eastern shore, where the Luo settled hundreds of years
>ago after traveling up the Nile from Sudan. Some of the customs
>that came with them would help AIDS along: Luo men are
>uncircumcised, a condition that in poor countries parallels
>increased risk of all sexually transmitted diseases. (In West
>Africa, where circumcision is far more common, there is a markedly
>lower AIDS rate.) The tribe also requires that a widow be wed to a
>relative of her late husband--a caretaking custom common across
>Africa, but practiced with particular strictness by the Luo.<p>
>
>The virus also created its own opportunities. Lake fishermen had
>always looked for female company after dragging their long, narrow
>boats ashore each morning. But only in recent years, after AIDS
>created widows with no other means of support, have women come
>down to the beach in numbers, trading sex for a portion of the
>catch.<p>
>
>"They call it 'extending the boat,' " said Jane Uwuor, a merchant
>in Usenge Beach.<p>
>
>By 1993, 20 percent of the residents of the area's large port
>city, Kisumu, tested positive for HIV. By 1998, the rate had
>galloped to 35 percent. Although rates varied widely, the same
>acceleration was seen across much of Africa, where 24.5 million
>people are estimated to carry the virus. In most places, because
>the disease can incubate in the body for more than 10 years,
>communities were slow to recognize how deeply it had settled in
>their midst.<p>
>
>"People don't believe anybody who hasn't got full-blown AIDS is
>infected," said Eric Otieng, a peer counselor.<p>
>
>The Luo saw the proof of the connection before most. So many in
>the tribe were infected in the early '90s that the approach of the
>millennium brought the reality home. The death toll of AIDS in
>Africa--5,500 a day, 2 million a year--became a family affair.
>While Andrecus Miruka's third wife watched her brother die, his
>second, Mary Anyango, lost two brothers, their wives, and four
>cousins.<p>
>
>And although the deaths were private, the burials were not. An
>African funeral is a major public occasion, a ritual of eulogy,
>burial, feasting and music that takes an entire day.
>Traditionally, that day is Saturday. But by the late '90s, so many
>were dying that "we bury every day of week," said Elijah Owaga, a
>Masogo minister.<p>
>
>People here say it was the explosion of funerals in the late 1990s
>that finally pushed AIDS into the open. As it happened, the first
>effective information campaign arrived in Masogo around the same
>time. With the British aid funds and a gifted local health worker
>named Alfred Abande, the Futures Group set about offering training
>on AIDS and other sexually transmitted diseases to a legion of
>community health workers.<p>
>
>The health workers, almost entirely women, were mostly midwives
>and traditional healers. They took what they learned into the
>homes around them--each assuming responsibility for 10 neighbors
>under the ambitious but geographically limited Futures plan. The
>agency even pays a stipend, though the women are urged to regard
>the $13 a month as temporary, and to generate income from chicken
>farms or other small trade that might sustain the program after
>the outside donor departs.<p>
>
>There are other compensations. The health worker positions carry a
>status that the women reinforced by sewing themselves uniforms of
>forest green. And to cement local support, "opinion leaders" were
>designated among the elders who retain significant authority even
>in a changing Africa. Miruka, named head of the Masogo panel,
>beams when he is called "chairman."<p>
>
>But if basic information on AIDS was, at long last, arriving in at
>least a few patches of western Kenya, there remained the question
>of what people would do with it. Infectious disease experts note
>with distress that the countries in Africa whose infection rates
>are among the highest--Botswana, Zimbabwe, South Africa--also
>boast the continent's best communication systems.<p>
>
>"The biggest gap is not in information," said Pisani, the medical
>demographer. "The biggest gap is turning that information into
>safer practice."<p>
>
>A little bit of knowledge, moreover, can be a dangerous thing.
>Along Kisumu's Beer Belt, a string of bars where commercial sex
>workers charge the equivalent of $2 for intercourse, health
>workers pressing the bar girls about condom use were stunned
>recently to hear this reply: Having heard that AIDS in Africa was
>a "heterosexual disease," the prostitutes had figured they could
>outfox the virus. They were offering customers unprotected anal
>sex--an extremely high-risk practice that spread the disease among
>gay men 20 years ago.<p>
>
>But there was also a hopeful precedent for changing behavior
>taking shape next door in Uganda. Ravaged by the disease in the
>early 1990s, the country was one of the first to launch an
>aggressive public education and prevention campaign. Led by
>President Yoweri Museveni, the abjectly poor country solicited
>foreign donors to support the effort. Although millions had
>perished, by the late '90s Uganda was the first African nation
>where the rate of new infections had declined. It became a model
>for the continent.<p>
>
>In Masogo, leaders, at least, appeared to be getting the message.
>Besides wearing the tall white cap of his office, Owaga, the
>minister, also worked as a "trainer of trainers," responsible for
>teaching basic primary health care to other lay health workers in
>his division, population 66,220. But as recently as two years ago
>he was still too poorly grounded about AIDS to feel comfortable
>enough to help a woman deliver a child, out of fear that the
>contact might infect him.<p>
>
>"I came with much fear," Owaga said. "I had not been so much
>informed on modes of transmission and infection."<p>
>
>Finally, in September 1998, he spent days learning specifics at a
>government health seminar. It made all the difference.<p>
>
>"Now I'm eager" to meet AIDS patients, Owaga said. "I even look
>for them. I don't want my people to suffer. I'm fully trained.
>Before, I could be suspicious, even resist. Now I feel like
>somebody involved. Because of the training."<p>
>
>
>A Dying Custom<p>
>
>There are other encouraging signs. The condom dispenser at the
>Masogo health center needs refilling every morning. The message
>Miruka took to delivering at funerals against wife inheritance
>appeared to be sinking in: Seven widows in his area have remained
>unmarried.<p>
>
>And, at least in the town center, the flow of information has
>reached a point where Jael Achieng, a community health worker,
>asked an American visitor about antiretroviral drugs, the
>still-expensive medicines that are extending life indefinitely
>among AIDS patients in the West.<p>
>
>"Would you mind sending us those drugs?" she asked. "Because our
>people are dying so much."<p>
>
>Despite drug companies' promise this year to lower prices on some
>treatments for AIDS, the life-saving drugs that cost $11,000 a
>year in the United States are not likely to slip under the $17 per
>capita Kenya now budgets each year for health care.<p>
>
>As a practical matter, medical experts are more encouraged by the
>Kenyan government's decision to allow AIDS awareness to be taught
>in school. The emphasis must be on children, they say, because
>after 20 years running almost unchecked in Africa, the virus has a
>depressingly firm grip on the sexually active adult population.<p>
>
>And as the epidemic reaches ever farther into the countryside,
>Masogo nurse Jane Nam noted another advantage of concentrating on
>youth.<p>
>
>"Schools are very near," she said. "It is health centers that are
>far away."<p>
>
>Ogilo Primary School stands just a couple of hundred yards behind
>Miruka's compound, a long house made of the same resilient mixture
>of cattle manure and soil as the homes. In the eight grades taught
>inside, the government curriculum includes daily religious
>studies; teachers spend perhaps 20 minutes a year on AIDS.<p>
>
>"We are not teaching it," said Lawrence Onyango, a teacher. Only
>in the STD unit in science, taught before the oldest (and most
>sparsely populated) classes, is the virus mentioned. "And maybe
>the prevention measures," he added.<p>
>
>In his role as an elder, Miruka also comes by to talk to the
>younger kids outside class. But as a Catholic in a country where
>bishops have burned condoms in public, he refrains from any
>mention of prophylactics for fear that it would amount to
>encouraging sex. (However, "If the school is for it, I'm ready to
>tell the children," he said.)<p>
>
>The Luo, like many African cultures, traditionally provided sex
>education of sorts in the home. Even 20 years ago, Miruka's eldest
>son was called into his grandfather's hut after the old man
>figured out that he had a girlfriend. "He used to tell me to lead
>a moral life, a disciplined life," Bernard Otieno said. The chat
>included a warning about sexually transmitted diseases.<p>
>
>Girls approaching puberty would share sleeping huts with a
>grandmother. She would tell them how to behave, and perhaps how,
>if her avid cousins could report from the wedding night sheets
>that she had been a virgin, her mother would be showered with
>cooking ash in congratulations.<p>
>
>By the time Domtila Awino was bunking with her "old mama," morals
>had relaxed enough that a girl might slip out for a few hours. But
>she had had only one boyfriend before Miruka gave her parents the
>five cows and 500 shillings that sealed their union.<p>
>
>"That's a dying custom," said Alfred Abande, the health worker,
>smiling at the sight of two men driving three hump-backed cattle
>down a lane at dusk. The suit jackets over their arms mean they
>are on their way to the bride's house, to pay dowry. "Most couples
>just run off to the city now." <p>
>
>And by the time they marry, surveys show that they have had
>perhaps a dozen sexual partners between them.<p>
>
>
>'The End Days'<p>
>
>"We don't follow customs anymore," declared Moses Omondi, 20, one
>of six modishly dressed young men who were seated recently in the
>shade behind Miruka's compound. "We live in the current world."<p>
>
>The men, aged 17 to 32 and free at midday on a workday, each
>nodded when Omondi said he almost never uses a condom.<p>
>
>"It's very rare," said Eric Owino, 23. The reasons he recites echo
>those of the male teachers at the Ogilo Primary School. Myths
>about reliability. Objections from women. ("She says it means you
>don't trust her.") Most of all, the lack of sensation.<p>
>
>"And then there is this thing in the Bible, too," said Moses
>Mbeda, 18. "In the Bible they say these are the End Days, and
>there will be a disease that has no cure."<p>
>
>"I believe so," said Omondi, to more nods. "The end of the world
>is about to come."<p>
>
>It's a matter of selecting what you want to believe. If a dying
>person has not been tested for AIDS, maybe he has chira, Omondi
>said: "Because you are married and you did not follow the
>rules."<p>
>
>Such a possibility--that AIDS is really not killing us--can also
>ease the way at a funeral, which has proven to be another
>tradition of Luo life still honored among the young. After the
>burial and the feast, there's almost always music. It might be Luo
>benga, or reggae. But usually it's the Congolese rock that all of
>Africa seems to love--dance music, endless and hypnotic and almost
>all hips.<p>
>
>"You talk, you dance, and at the end you end up engaging in sex,"
>Owino said. "You don't have a condom. . . ." He shrugged.
>"Sometimes it's very hard to reverse nature."





============================================================

In the early 90's we found that the US embassy in South Africa was obtaining
every scap of info on Aids that it could...including the ambasssador.   I
can now see who was giving the orders.

John

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