Illustration by Stanley Martucci and Cheryl Griesbach
Additional articles in this series.
Penhalonga, Zimbabwe�They didn't call Arthur Chinaka out of the classroom. The principal and Arthur's uncle Simon waited until the day's exams were done before breaking the news: Arthur's father, his body wracked with pneumonia, had finally died of AIDS. They were worried that Arthur would panic, but at 17 years old, he didn't. He still had two days of tests, so while his father lay in the morgue, Arthur finished his exams. That happened in 1990. Then in 1992, Arthur's uncle Edward died of AIDS. In 1994, his uncle Richard died of AIDS. In 1996, his uncle Alex died of AIDS. All of them are buried on the homestead where they grew up and where their parents and Arthur still live, a collection of thatch-roofed huts in the mountains near Mutare, by Zimbabwe's border with Mozambique. But HIV hasn't finished with this family. In April, a fourth uncle lay coughing in his hut, and the virus had blinded Arthur's aunt
Eunice, leaving her so thin and weak she couldn't walk without help. By September both were dead.
The most horrifying part of this story is that it is not unique. In Uganda, a business executive named Tonny, who asked that his last name not be used, lost two brothers and a sister to AIDS, while his wife lost her brother to the virus. In the rural hills of South Africa's KwaZulu Natal province, Bonisile Ngema lost her son and daughter-in-law, so she tries to support her granddaughter and her own aged mother by selling potatoes. Her dead son was the breadwinner for the whole extended family, and now she feels like an orphan.
In the morgue of Zimbabwe's Parirenyatwa Hospital, head mortician Paul Tabvemhiri opens the door to the large cold room that holds cadavers. But it's impossible to walk in because so many bodies lie on the floor, wrapped in blankets from their deathbeds or dressed in the clothes they died in. Along the walls, corpses are packed two to a shelf. In a second cold-storage area, the shelves are narrower, so Tabvemhiri faces a
grisly choice: He can stack the bodies on top of one another, which squishes the face and makes it hard for relatives to identify the body, or he can leave the cadavers out in the hall, unrefrigerated. He refuses to deform bodies, and so a pair of corpses lie outside on gurneys behind a curtain. The odor of decomposition is faint but clear.
Have they always had to leave bodies in the hall? "No, no, no," says Tabvemhiri, who has worked in the morgue since 1976. "Only in the last five or six years," which is when AIDS deaths here took off. Morgue records show that the number of cadavers has almost tripled since the start of Zimbabwe's epidemic, and there's been a change in who is dying: "The young ones," says Tabvemhiri, "are coming in bulk."
The wide crescent of East and Southern Africa that sweeps down from Mount Kenya and around the Cape of Good Hope is the
hardest-hit AIDS region in the world. Here, the virus is cutting down more and more of Africa's most energetic and productive people, adults aged 15 to 49. The slave trade also targeted people in their prime, killing or sending into bondage perhaps 25 million people. But that happened over four centuries. Only 17 years have passed since AIDS was first found in Africa, on the shores of Lake Victoria, yet according to the Joint United Nations Programme on HIV/AIDS (UNAIDS), the virus has already killed more than 11 million sub-Saharan Africans. More than 22 million others are infected.
Only 10 percent of the world's population lives south of the Sahara, but the region is home to two-thirds of the world's HIV-positive people, and it has suffered more than 80 percent of all AIDS deaths.
Last year, the combined wars in Africa killed 200,000 people. AIDS killed 10 times that number. Indeed, more people succumbed to HIV last year than to any other cause of death on this continent, including malaria. And the carnage has only begun.
Unlike ebola or influenza, AIDS is a slow plague, gestating in individuals for five to 10 years before killing them. Across East and Southern Africa, more than 13 percent of adults are infected with HIV, according to UNAIDS. And in three countries, including Zimbabwe, more than a quarter of adults carry the virus. In some districts, the rates are even higher: In one study, a staggering 59 percent of women attending prenatal clinics in rural Beitbridge, Zimbabwe, tested HIV-positive.
Life expectancy in more than a dozen African countries "will soon be 17 years shorter because of AIDS-47 years instead of 64," says Callisto Madavo, the World Bank's vice president for Africa. HIV "is quite literally robbing Africa of a quarter of our lives."
In the West, meanwhile, the HIV death rate has dropped steeply thanks to powerful drug cocktails that keep the disease from progressing. These regimens must be taken for years, probably for life, and they can cost more than $10,000 per patient per year. Yet in many of the hardest-hit African countries, the total per capita health-care budget is less than $10.
Many people-in Africa as well as the West-shrug off this stark disparity, contending that it is also true for other diseases. But it isn't. Drugs for the world's major infectious killers-tuberculosis, malaria, and diarrheal diseases- have been subsidized by the international community for years, as have vaccines for childhood illnesses such as polio and measles. But even at discounted prices, the annual cost of putting every African with HIV on triple combination therapy would exceed $150 billion, so the world is letting a leading infectious killer for which treatment exists mow down millions.
That might be more palatable if there were a Marshall Plan for AIDS prevention to slow the virus's spread. But a recent study by UNAIDS and Harvard shows that in 1997 international donor countries devoted $150 million to AIDS prevention in Africa. That's less than the cost of the movie Wild Wild West.
Meanwhile, the epidemic is seeping into Central and West Africa. More than a tenth of adults in C�te d'Ivoire are infected. Frightening increases have been documented in Yaound� and Douala, the largest cities in Cameroon. And in Nigeria-the continent's most populous country-past military dictatorships let the AIDS control program wither, even while the prevalence of HIV has climbed to almost one in every 20 adults.
Quite simply, AIDS is on track to dwarf every catastrophe in Africa's recorded history. It is stunting development, threatening the economy, and transforming cultural traditions.
Epidemics are never merely biological. Even as HIV changes African society, it spreads by exploiting current cultural and economic conditions. "The epidemic gets real only in a context," says Elhadj Sy, head of UNAIDS's East and Southern Africa Team. "In Africa, people wake up in the morning and try to survive-but the way they do that often puts them at risk for infection." For example, men migrate to cities in search of jobs; away from their wives and families for months on end, they seek sexual release with women who, bereft of property and job skills, are selling their bodies to feed themselves and their children. Back home, wives who ask their husbands to wear condoms risk being accused of sleeping around; in African cultures, it's usually the man who dictates when and how sex happens.
Challenging such cultural and economic forces requires political will, but most African governments have been shockingly derelict. Lacking leadership, ordinary Africans have been slow to confront the disease. Few companies, for example, have comprehensive AIDS programs. And many families still refuse to acknowledge that HIV is killing their relatives, preferring to say that the person died of TB or some other opportunistic illness. Doctors often collude in this denial. "Just the other day," says a high-ranking Zimbabwean physician who spoke on condition of anonymity, "I wrote AIDS on a death certificate and then crossed it out. I thought, 'I'll just be stigmatizing this person, because no one else puts AIDS as the cause of death, even when that's what it is.' "
Why is AIDS worse in sub-Saharan Africa than anywhere else in the world? Partly because of denial; partly because the virus almost certainly originated here, giving it more time to spread; but largely because Africa was weakened by 500 years of slavery and colonialism. Indeed, historians lay much of the blame on colonialism for Africa's many corrupt and autocratic governments, which hoard resources that could fight the epidemic. Africa, conquered and denigrated, was never allowed to incorporate international innovations on its own terms, as, for example, Japan did.
This colonial legacy poisons more than politics. Some observers attribute the spread of HIV to polygamy, a tradition in many African cultures. But job migration, urbanization, and social dislocation have created a caricature of traditional polygamy. Men have many partners not through marriage but through prostitution or sugar-daddy arrangements that lack the social glue of the old polygamy.
Of course, the worst legacy of whites in Africa is poverty, which fuels the epidemic in countless ways. Having a sexually transmitted disease multiplies the chances of spreading and contracting HIV, but few Africans obtain effective treatment because the clinic is too expensive or too far away. Africa's wealth was either funneled to the West or restricted to white settlers who barred blacks from full participation in the economy. In apartheid South Africa, blacks were either not educated at all or taught only enough to be servants. Now, as the country suffers one of the world's most explosive AIDS epidemics, illiteracy hampers prevention. Indeed, AIDS itself is rendering Africa still more vulnerable to any future catastrophe, continuing history's vicious cycle.
Yet AIDS is not merely a tale of despair. Increasingly, Africans are banding together- usually with meager resources-to care for their sick, raise their orphans, and prevent the virus from claiming more of their loved ones. Their efforts offer hope. For while a crisis of this magnitude can disintegrate society, it can also unify it. "To solve HIV," says Sy, "you must involve yourself: your attitudes and behavior and beliefs. It touches upon the most fundamental social and cultural things-procreation and death."
AIDS is driving a new candor about sex-as well as new efforts to control it, through virginity testing and campaigns that advocate sticking to one partner. And slowly, fitfully, it is also giving women more power. The death toll is scaring women into saying no to sex or insisting on condoms. And as widows proliferate, people are beginning to see the harm in denying them the right to inherit property.
The epidemic is also transforming kinship networks, which have been the heart of most African cultures. Orphans, for example, have always been enfolded into the extended family. But more than 7 million children in sub-Saharan Africa have lost one or both parents, and the virus is also killing their aunts and uncles, depriving them of foster parents and leaving them to live with often feeble grandparents. In
response, communities across Africa are volunteering to help orphans through home visits and, incredibly, by sharing the very little they have. Such volunteerism is both a reclaiming of communal traditions and their adaptation into new forms of civil society.
But even heroic efforts can't stop the damage that's already occurred here in the hills where Arthur Chinaka lost his father and uncles. The worst consequence of this epidemic is not the dead, but the living they leave behind.
Rusina Kasongo lives a couple of hills over from Chinaka. Like a lot of elderly rural folk who never went to school, Kasongo can't calculate how old she is, but she can count her losses: Two of her sons, one of her daughters, and all their spouses died of AIDS, and her husband died in an accident. Alone, she is rearing 10 orphaned children.
"Sometimes the children go out and come home very late," says Kasongo, "and I'm afraid they'll end up doing the same thing as Tanyaradzwa." That's the daughter who died
of AIDS; she had married twice, the first time in a shotgun wedding. Now, the eldest orphan, 17-year-old Fortunate, already has a child but not a husband.
Few people have conducted more research on AIDS orphans than pediatrician Geoff Foster, who founded the Family AIDS Caring Trust (FACT). It was Foster who documented that more than half of Zimbabwe's orphans are being cared for by grandparents, usually grandmothers who had nursed their own children to the grave. But even this fragile safety net won't be there for many of the next generation of orphans.
"Perhaps one-third of children in Zimbabwe will have lost a father or mother-or both-to AIDS," says Foster. They are more likely to be poor, he explains, more likely to be deprived of education, more likely to be abused or neglected or stigmatized, more likely to be seething with all the needs that make it more likely that a person will have unsafe sex. "But when they get HIV and die, who cares for their children? Nobody, because they're orphans, so by definition their kids have no grandparents. It's just like the virus itself. In the body, HIV gets into the defense system and knocks it out. It does that sociologically, too. It gets into the extended family support system and decimates it."
Foster's chilling realization is dawning on other people who work in fields far removed from HIV. This year, South African crime researcher Martin Sch�nteich published a paper that begins by noting, "In a decade's time every fourth South African will be aged between 15 and 24. It is at this age group where people's propensity to commit crime is at its highest. At about the same time there will be a boom in South Africa's orphan population as the Aids epidemic takes its toll." While some causes of crime can be curtailed, Sch�nteich writes,
"Other causes, such as large numbers of juveniles in the general population, and a high proportion of children brought up without adequate parental supervision, are beyond the control of the state." His conclusion: "No amount of state spending on the criminal justice system will be able to counter this harsh reality."
More AIDS and more crime are among the most dramatic consequences of the orphan explosion. But Nengomasha Willard sees damage that is harder to measure. Willard teaches 11-and 12-year-olds at Saint George's Primary School, located near the Chinakas and the Kasongos. Fifteen of Willard's 42 pupils have lost one or both of their parents, but he's particularly worried about one of his students who lost his father and then, at his mother's funeral, cried inconsolably. "He doesn't want to participate," says Willard. "He just wants to be alone."
"I see thousands of children sitting in a corner," says Foster. "The impact is internalized-it's depression, being withdrawn." In Africa, says Foster, the focus on poverty eclipses research into psychological issues, but he has published disturbing evidence of abuse-emotional, physical, and sexual. Meanwhile, the orphan ranks keep swelling. "We're talking 10 percent who will have lost both parents, maybe 15 percent. Twenty-five percent who will have lost a mother. What does that do to a society, especially an impoverished society?"
Among his students, Willard has noticed that some of the orphans come to school without shoes or, in Zimbabwe's cold winter, without a sweater. Sometimes their stepfamilies put them last on the list, but often it's because grandmothers can't scrape together enough money.
Among economists, there has been a quiet debate over whether HIV will harm the economy. Some think it won't. With unemployment rates in sub-Saharan Africa between 30 and 70 percent, they reason that there are plenty of people to replenish labor losses. One scenario is that economic growth might slacken, but population growth will also dwindle, so per capita GNP might hold steady or even rise. Then, says Helen Jackson, executive director of the Southern Africa AIDS Information Dissemination Service (SAfAIDS), Africa might face the grotesque irony of "an improvement in some macroeconomic indicators, but the exact opposite at the level of households and human suffering."
But evidence is mounting that the economy will suffer. Between 20 and 30 percent of workers in South Africa's gold mining industry-the mainstay of that country's economy-are estimated to be HIV-positive, and replacing these workers will cut into the industry's productivity. In Kenya, a new government report predicts that per capita income could sink by 10 percent over the next five years. In C�te d'Ivoire, a teacher dies every school day.
Then there are the effects that can't be quantified. "What does AIDS do for the image of Africa?" asks Tony Barnett, a veteran researcher on the economic impact of AIDS. To lure investors, the continent already has to battle underdevelopment and racism, but now, he says, many people will see Africa as "diseased, sexually diseased. It chimes in with so many stereotypes."
Beneath the corporate economy, millions of Africans subsist by cultivating their own small plot of land. When someone in the family comes down with AIDS, the other members have to spend time caring for that person, which means less time cultivating crops. And when death comes, the family loses a crucial worker. Studies have documented that among rural AIDS-stricken families, food production falls, savings dwindle, and children are more likely to be undernourished.
For Kasongo and her 10 orphans, food is a constant problem, but now it has become even harder. On her way back from the fields, carrying a basket of maize on her head, Kasongo tripped and fell. Her knee is swollen, her back is aching, and cultivating the fields is close to impossible. Here, under the radar of macroeconomic indicators, Kasongo's ordeal shows how AIDS is devastating Africa.
This is the context in which one of Africa's most agonizing debates is taking place: Should doctors administer drugs to pregnant women that sharply reduce the chances that a baby will be born with HIV? So far, the debate has centered on the cost of the drugs, but a new, inexpensive regimen has pushed thornier arguments to the surface.
The "vaccine for babies," as it is sometimes called, does not treat the mother and so does nothing to reduce the chances the baby will become an orphan. That's why Uganda's Major Rubaramira Ruranga, a well-known activist who is himself infected with HIV, opposes it. "Many children in our countries die of malnutrition, even with both parents," he argues. "Without parents, it's almost certain they'll die."
Isn't it impossible to know the fate of any
given child and presumptuous to decide it in
advance? "That's sentimental," he snaps. Even Foster, who believes "every child has a right to be born without HIV," wonders whether the money is best spent on the "technical fix" of giving drugs to the pregnant women. The medicine is only a part of the cost, for women can infect their children during breast feeding, which raises expensive problems such as providing formula and teaching mothers how to use it safely in places where clean water may not exist. Would all that money, Foster wonders, be better spent alleviating the root causes of why women get infected in the first place? "It's very difficult to stand up and make such an argument because you get portrayed as a beast," he says. In fact, such arguments testify to how the epidemic is forcing Africans to grapple with impossible choices.
Weston Tizora is one of thousands of Africans who are trying to give orphans a decent life. Just 25 years old, Tizora started as a gardener at Saint Augustine's Mission and threw himself into volunteering in the mission's AIDS program, called Kubatana, a Shona word meaning "together." Next year he will take over the program's leadership from its founder, British nurse Sarah Hinton. Kubatana's 37 volunteers care for homebound patients, and they help raise orphans by, for example, bringing food to Rusina Kasongo's brood.
Just a few steps from Kasongo live Cloud and Joseph Tineti. They're 14 and 11, respectively, and the oldest person in their home is their 15-year-old brother. They are, in the language of AIDS workers, a child-headed household. Who's in charge? "No one," Joseph answers-and it shows. Their one-room shack is strewn with dirty clothes, unwashed dishes, broken chairs. On the table, a roiling mass of ants feasts on pumpkin seeds and some kind of dried leaves.
The troubles run deeper. Their father, who had divorced their mother before she died, lives in nearby Mutare. Does he bring food? "Yes," says Joseph, "every week." It's not true, Tizora maintains. Kubatana members have even talked with the police in their effort to convince the father to take in his children or at least support them. But the police did not act, explains Tizora, because the father is unemployed and struggling to provide for the family of his second wife. Once a month-sometimes not even that often-he brings small amounts of food, so the orphans depend on donations from Kubatana volunteers.
But if little Joseph's version isn't true, it's what an orphaned kid would want: a father who at least brings food, stops by frequently, and acts a little like a dad. And his mother: What does Joseph remember of her? The question is too much, and he starts crying.
Kubatana volunteers are supposed to look after the Tineti orphans, so why is their home so unkempt? There used to be two volunteers in this area, explains Tizora. One has been reassigned to work in the nearby mining village, ravaged by AIDS. The other has been away at her parents' home for two months, attending to a family funeral and to her own late-stage pregnancy.
And everyone in these villages has their hands full. Standing in a valley, Tizora points to the hillsides around him and says, "There are orphans in that home, and the one over there, and there by the gum trees. And see where there's that white house? They're taking care of orphans there, too." By the time he finishes, he has pointed out about half of the homesteads. When the Kubatana program started, in 1992, volunteers identified 20 orphans. Now they have registered 3000. In many parts of Africa, notes Jackson of SAfAIDS, "It has actually become the norm to have orphaned children in the household rather than the exception."
Foster makes some quick calculations: Given the number of volunteers in the Kubatana program, there's no way they can care for all their orphans. So when a volunteer gets pregnant, has a family emergency, or gets sick, kids like Cloud and Joseph fall through the cracks. Says Foster: "You can't lose a quarter of your adult population in 10 years without catastrophic consequences."
In his office, Tizora has a wall of photographs showing the original 20 orphans. One is a girl who looks about 12. She lost her parents and then she lost the grandma who was caring for her. At that point, she started refusing to go to school, hiding on the way there. Now, she's run away and, Tizora says, "we don't know where she is."