Out of Africa: Part two

By Celia Farber
Spin March 1993

Is there really an epidemic of AIDS in Africa? Is it comparable to AIDS in the United States? In part two, Celia Farber concludes her journey through Africa.

As reported in part one of this article last month, the actual figures for AIDS, though it is said to be ravaging central Africa and decimating entire populations, are surprisingly low, much lower than those in the United States. The entire continent of Africa has reported only 151,455 cases of AIDS while the cumulative total for the United States is 230,179. HIV is indeed more widespread in Africa than it is here, but the extrapolations made about the number of deaths that would result from these HIV­positive cases turn out to be wildly exaggerated.

The health profile of sub­Saharan African nations is incomparable with that of industrialized nations. Parasitic infections, tuberculosis, malaria, cholera, and many other diseases are on the rise in central Africa and are often indistinguishable from what is called "slim disease," or AIDS. There is very little reliable diagnostic testing for HIV, and still more unsettling is the fact that AIDS is often diagnosed even when HIV is not present. The symptoms of slim are old and familiar to the continent of Africa: diarrhea, fever, wasting, coughing, vomiting" etc. Nobody has suggested that these symptoms are new, but what is said to be new is the epidemic proportions they have recently taken. Indeed, people are dying at an alarming rate in sub­Saharan Africa; the question is how many of those deaths are really "AIDS"-what we call AIDS, i.e. a deadly, communicable disease presumed to be caused by the retrovirus HIV.

I traveled to Cote d'lvoire, Uganda, and Kenya, three of the African countries said to be hardest hit by AIDS, with two others: Joan Shenton, a British documentary producer who was preparing a documentary on AIDS in Africa for Dispatches on U.K.'s Channel Four, and Dr. Harvey Bialy, a molecular biologist and scientific editor for the journal Bio/Technology, who had spent many years working in West Africa as a tropical disease expert.

Most of the African doctors we interviewed admitted they were confused regarding the definition of what exactly AIDS in Africa is. They stressed that something new had occurred, that people were falling ill and dying in far greater numbers than they had ever seen. Other doctors differed, however, and said they were not so sure there was anything new, that they had not seen what they would call an epidemic of AIDS.

Given the poverty­stricken living conditions of a country such as Uganda, it is extremely difficult to determine where the classic disease­inducing environmental conditions such as filthy water, malnourishment, and lack of health care leave off and a new viral epidemic picks up. But the tragic irony of the hype surrounding AIDS in Africa is that the various educational programs sponsored by AIDS organizations and the World Health Organization (WHO) seem to have, at least in certain ways, made the situation worse. Relief workers in the afflicted regions of Uganda and Tanzania spoke of a psychological affliction called "AIDS brain," in which people have become so petrified of AIDS that they become sick regardless of whether they have HIV or not. And safe sex programs have not just failed but backfired, because, as Ugandan journalist Samuel Mulondo put it, "People don't give a damn. They've been told that 80 percent are infected, that they're going to die, that there's no way out, so people are trying to enjoy themselves. They say, 'We're all gone anyway. We're dead.' This is the result of these exaggerated AIDS education scare campaigns."

Meanwhile, financial interests appear to be fanning the flames. The WHO allotted $6 million AIDS education in Uganda in a single year, while all other infectious diseases combined received a mere $57,000. We were warned by an African physician working in London that many doctors in Africa depend on the exaggerated African AIDS statistics for their livelihood. "When they go to these AIDS conferences around the world," he said, "the per diem they are given is what they make in an entire year at home."

Rakai District, Uganda

It was a muggy, rainy day in Rakai, and the car we were driving felt as if it had no tires. The road was a deep red color and stretched out endlessly in front of us as we rattled toward our destination, the Rakai district of Uganda, said to be the AIDS epicenter of the world. In the car with me were two men who work for an organization for AIDS orphans in Rakai and Samuel Mulondo, the Radio Uganda journalist I had brought with me from Kampala as an interpreter. Sam had taken great care in selecting our driver, explaining that all of the drivers hired through the tourist hotels in Kampala were government informers. "All of them?," I asked, skeptically. "Yes, all of them," he replied.

When Sam and I were planning this excursion in Kampala, a few days earlier, he detailed for me the web of bureaucratic obstacles we would have to navigate before setting off recited a litany of ministries-in order to visit the Rakai district we would need to obtain written permission from the Ministry of Health for the Rakai district, then the Ministry of AIDS, the Ministry of Information, and so on. We spent nearly a whole day crisscrossing Kampala so these various ministries, which all directed us back to one of the others. We needed a written request, a letter from this and that minister granting permission, then a stamp from one of the other ministries, before the next ministry would even look at it. By the end of the day, still not recognizably closer to having obtained permission, we realized we were being kept in a holding pattern. "Okay, let's just go," Sam said finally.

Sam has to be extremely cautious when he delivers his AIDS reports on Radio Uganda, and he had already received several warnings. His personal opinion, based on years of reporting, is that there is no real epidemic of AIDS in Africa, that what people are dying of is no different than it's ever been-namely, diseases that have always plagued Africa-malaria, meningitis, cholera, typhoid, TB and poverty, malnutrition, and a near total absence of health care. Further, he feels that the money being sent from the West to fight AIDS was being used to "benefit certain individuals," but was not trickling down to the people who were supposedly suffering from AIDS. That's why he suggested we go to the Rakai district.

"You'll see," he said. "The people there have nothing. No medication, nothing."

As we left Radio Uganda, Sam caught sight of one of the ministers whose permission we needed. He waved to him across the street, and we quickened our pace to catch up. "I know him," Sam whispered. "Just play dumb Western reporter here to do an AIDS story. Tell him you want to write about the orphans. Nothing else." Sam warned me that a Japanese film crew had been chucked out of the Rakai district and their film confiscated because the government didn't like what they were reporting.

We followed the minister into a large, stone building, up a swirling staircase and into his office, where we sat down in two huge, red leather chairs. He leaned back in his chair and looked at me suspiciously. What did I want? I smiled and said I wanted to write about the orphans, for a young people's magazine in America.

"Young people in particular," I said, "need to understand how serious the AIDS situation is here. So that perhaps we can prevent the same thing from happening to us."

I couldn't imagine that he would buy that, but he finally grunted and said we could use his name at the next ministry and say he'd given us clearance. We thanked him profusely and hurried out.

Sam sat stonefaced, staring out the car window. The two men from the orphan organization had decided which orphanage to take us to and were instructing the driver. We turned off the main road and started driving through thick, lush terrain on small dirt roads. Finally, we entered a clearing, with a gray stone house built squarely in the middle. A group of about 30 children stood in front of the house, staring fixedly at the car as we approached. When we got out of the car, all the children scurried into neat rows, hands at their sides. The two men introduced us and they called out a greeting in unison. When the men gave the word, they dispersed.

I became transfixed by them. They did not seem at all miserable quite the opposite, they were the most exuberant children I'd ever seen, laughing and playing, the bigger ones carrying the smaller ones around on their backs. A few of them came up to me and curtsied, and when I smiled at them, their faces just lit up. And there they were, living in an empty house in the bush with nothing, not even parents. The house turned out to be a single room. "Do they all live here?" I asked. The answer was yes. "And where do they sleep?"

"On the floor."

I was ushered inside. Sitting on a bench was an old woman wringing her hands, her eyes fixed on the floor. One of the men explained that six of her ten children had died of AIDS. I sat down to talk to her, and Sam interpreted.

All of them were sons, she said, two of them left no children. The cause of death in all six cases was diarrhea. I asked whether she had ever seen anything like this disease before. She said: "We have been suffering from this illness, diarrhea, for a very long time, but these days it doesn't stop. One of them was so wasted away you couldn't recognize that he was a human being."

"Did they all have HIV?" I asked."

"Yes, apart from one who was 13 years old. He had malaria. And another one, also age 13, who died of typhoid."

She was wearing a bright purple gown. She barely looked at me, her eyes stayed on the floor, she had no spirit left. I sat next to her, stiff with discomfort, feeling like some kind of vulture, picking at the bones of human experience, and then flying off again. This is what's appalling about being a journalist in a situation like this, rather than interacting as a human would, with a touch, a few words of encouragement, anything-out comes your little investigative needle, poking and prodding for the facts. I didn't want to ask her anything, but I had to.

Because this is where the whole picture fades into a blur. It happened over and over, particularly in these villages, that I was told of a string of AIDS deaths, which were suddenly called malaria, typhoid, TB, or whatever. I had to ask her why, if at least two of her sons died of other diseases, she felt that all six had died of AIDS, but she looked at me blankly and Sam whispered, "She will tell you what she has been told, that it is HIV, and that it is sexually transmitted."

I asked her what the difference was, as far as she could observe, between this AIDS epidemic and diseases people got before. She said, "The difference is that when people got these diseases before, they would get an injection and they would get better. Now they only get worse and they die." I asked about the two sons who had malaria and typhoid. Had they received treatment?

"Yes," she said, "they did. But they died anyway."

Dr. Harvey Bialy, who worked with tropical diseases in West Africa for many years, says, "All parasitic infections are at least somewhat immunesuppressive. There is little difference between the immune system of a so­called AIDS patient and an undernourished one who suffered chronic parasitic infections."

If the old woman's story is typical-and it was a story I heard many, many versions of-it seems clear that, despite medical intervention, people in Uganda are dying-young-of several old, familiar diseases. Whether they are HIV­positive or not. Furthermore, the life expectancy in Uganda, as in many African countries, is only around 44 years old.

In Africa, the danger of misdiagnosed AIDS cases is not the same as it is here, namely the threat of highly toxic antiretroviral therapy, such as AZT and ddI, but more of a social one. People said to have AIDS are horribly stigmatized, sometimes banished from their villages and left to die, often not treated at all if they do make it to a hospital, not to mention the unspeakable terror, and the fixed death sentence that accompanies an AIDS diagnosis. Added to that, there is the guilt associated with the notion that AIDS, as opposed to other tropical diseases, is said to be a sexually transmitted disease. Blame falls squarely at the feet of the AIDS patient, while the socioeconomic setting is ignored-a scenario that is unsettlingly convenient for the establishment. The appalling conditions of life in Africa are discounted as a health factor and momentum is given to the politically correct, simplistic, and unproven party line that AIDS is going to get everyone, and that sex is the primary cause

Eighty percent of AIDS is said to be sexually transmitted in Africa. And yet, although 50 percent of the prostitutes in Abidjan, Cote d'lvoire, for instance, are estimated to be infected with HIV, very few have developed AIDS. At the major infectious disease clinic in Abidjan, which handles most of

Abidjan's AIDS cases, the director told us that he hardly saw any cases of AIDS in prostitutes. Nor did he see any IV­drug users or gay men. Likewise in Kenya, where 80 percent of the prostitutes are said to be infected with HIV, very few have AIDS. A lab technician we spoke to in Nairobi, Kenya, who worked with HIV testing, confirmed, "Most people with HIV here in Africa stay healthy. The prostitutes have remained healthy."

One doctor in Nairobi, who treats many AIDS patients, Dr. Manohar Nene, was quite upset about the emphasis on sex as opposed to other factors. "We have psychologically upset the sexually active population of the world. If you upset people's notion of sex, it is terribly disruptive."

Nene said he does not believe AIDS, or HIV at least, is sexually transmitted, because the number of infected cells in semen is so low.

"Personally, I think it's not sexually transmitted," he said. "When you make people feel guilty about sex, which is a natural thing, you add a stress, and stress can cause disease." A poster in the lobby we passed on the way to his office showed a heart with a worm crawling through it. It read, "Careless sex is a fruit with a worm in it. AIDS."

Which brings us to another mystery, namely why it is that in Africa, HIV is said to be as easily transmisted between men and women, whereas in the West, there are hardly any heterosexual men with either HIV or AIDS. If you don't believe that, then consider the following statistic from the New York City Department of Health: Number of men who have acquired AIDS from women in New York, all five boroughs, since the beginning of the epidemic: 20.

How can we assume, for instance, that the old woman's sons were heterosexual? Mainly from the fact that four of them were married and had children. Assuming that most of the African men who "get HIV and AIDS" do so via heterosexual contact, then who are they getting it from? In Africa, the dots don't necessarily connect sexually. In the old woman's case, for instance, none of the men's wives were sick. In these parts, I was told, the men die at a much faster rate than the women. Overall in central Africa, the ratio of men to women with AIDS is said to be three to one. When the men die, the (healthy) women typically remarry, and then give birth to perfectly healthy children. And even the women who do get sick give birth to healthy children. I spoke to one boy of about 13 who said his mother had died of slim, and he had seven healthy brothers and sisters, one as young as a year and a half There were also cases in the Rakai district of men who had lost up to four successive wives to "AIDS," and in one case, five over the last decade, while the men remained in good health.

So­called "discordant" couples, where one partner is sick, HIV­positive, or has died of AIDS, while the other is HIV­negative and healthy, are common in the West and also in Africa. One virologist in Rakai filed cases of 30 such discordant couples.

I bid the old woman goodbye and thanked her. As I was walking out, one of the men said, "Excuse me, madam, the children wart to sing you a farewell song."

Outside the door the children stood clustered, and to my amazement, they opened their mouths and started to sing the most beautiful song I've ever heard.

We walked toward the car and one of the two men said, "Somebody in the next village has just died of slim. We want to take you there."

I looked at Sam, whose face betrayed nothing.

"Somebody just died?"

"Yes", he said, "Let's go."

I hesitated before getting in the car. Why were they so eager for me to see a corpse?

We drove deeper into the bush until we reached another clearing.

This one seemed to be a little village, with a small cluster of huts. There was garbage everywhere, and plastic bowls in bright colors, and coils of black smoke rising here and there, but no food. It was very quiet; the only sound was the tap of the rain. We walked up to one of the huts. inside, the floor of the hut was filled with women sitting on the floor. In the middle of the hut, against the wall, was a coffin. A candle and a picture of Christ hung over it. One older woman was draped over the coffin, sobbing, the others sat very still and quiet, looking on. Outside, another 20 or so women gathered.

I felt very uncomfortable, very invasive, and I whispered to one of the men, "Thank you, but can we go now?" But he started motioning me into the hut, pointing to the coffin. He virtually pushed me up to the doorway where I stood transfixed as one of the women slowly lifted the lid of the coffin and then started to peel away the layers of white cloth that covered the dead man's face. When the crying woman caught sight of her son's face, she let out a loud cry and one of the other women gripped her. His face was gaunt and his nostrils were stuffed with cotton. He looked about 30.

I don't know anything about the man, his history, or the cause of his death. I don't know whether he died of AIDS. But it struck me as slightly odd that the two gentlemen from the AIDS organization seemed so intent on showing me this dead man, and they kept saying, over and over, that he had died of AIDS. I don't know whether he had even been to a hospital, had ever been tested for HIV. But they did say that he hadn't been sick for long, which was rather typical. Scores of men getting sick and dying within a matter of months is not a description that fits what we in the West refer to as AIDS. Are there other diseases that behave radically differently on different continents?

"No," says Bialy. "Why should African AIDS be any different than AIDS in any other country? Do we have French AIDS? Brazilian AIDS? The definition of this thing gets more and more nebulous all the time. At this point, you may as well call anything AIDS."

Kampala, Uganda

There was an herbal doctor who treated AIDS patients in Kampala whom Sam wanted me to meet. Downtown Kampala is dusty, torn, and chaotic, as if recently bombed. I followed Sam through the streets and down an alleyway, over which hung a crooked sign that read "Clinic for AIDS Research." Like everything in Uganda, the doctor's office was cramped, dark, and rickety. People were packed into the tiny area like commuters at rush hour. We had to push our way through to the doctor, who sat in a little fluorescent­lit cubicle.

Sam introduced me, and the doctor shook my hand and started talking about his treatments. He had learned the recipes from his grandfather, and he claimed to be the only doctor in Kampala who was having success with AIDS patients. He knew how to stop the diarrhea. He hollered to an assistant and a hand holding a bottle of medicine came through a side window covered by a little red curtain. He held up the bottle. "This is for diarrhea," he said. It was a mixture of honey and herbs. Then he started hollering again, and more and more bottles came through the window, until he was surrounded by bottles. They had funny names on the labels such as "Red Hot Devil Liquid."

He said he treated several hundred patients per day. People were clamoring toward the back room, where the bottles were kept in huge baskets. One man grabbed my arm and wouldn't let me go until he had convinced me that this man had cured him and several of his friends of slim.

Well, I hope so. And I was delighted to note that AZT was virtually nonexistent in Africa. I didn't meet a single doctor who was even remotely interested in AZT. As one put it, "it doesn't work, does it? So it's just as well that we can't afford it.

"AZT does not cure AIDS, is very expensive, and causes too many complications," said Dr. Kassi Manlan, director general of health and social services for Cote d'Ivoire, explaining why Cote d'Ivoire does not use AZT for AIDS. The entire annual health­care budget for the country would be spent if just 1,000 people were treated with AZT.

Entebbe, Kampala

It was an eerie drive from the airport in Entebbe back to the hotel in Kampala. Prior to Idi Amin, prior to the last three decades, Uganda was known as "the pearl of Africa," and was said to be one of the most beautiful places on earth. Some say that the Garden of Eden was in Uganda. Now it is one of the poorest, most disease­ridden countries in Africa. It is also known as the AIDS center of the world. The road to Kampala was lined with people building and selling coffins. Simple wooden boxes with black crosses on the front.

Sam and I were looking for a place to have lunch in downtown Kampala. We went to a roadside cafe and ordered grilled chicken. Upon asking for a toilet, I was shown through the kitchen and into the backyard, where a whole separate world was bubbling. There were chicken parts everywhere- heads, feet, feathers, and live chickens pecking in the mud- women standing over vats of dirty water, rinsing potatoes in them, coils of black smoke, and a rancid, oily­stench. The toilet was a shack with a hole in the ground. In fact, every toilet I saw in Uganda, except in the hotel, was a hole in the ground. I went to inspect the toilets at Mulago hospital, the major hospital in Kampala, and even there-a hole in the floor, covered in excrement and buzzing with flies.

Although the poverty in Uganda was shocking and brutal, it wasn't the most distressing thing about it. The real depressing thing was the lack of any kind of infrastructure. It seemed like chaos on earth, genuine chaos. When Joan and I were sitting in the airport, waiting to fly to Nairobi, I looked up and noticed the airport lounge had no ceiling. All the wiring was hanging down, plaster falling. it seemed to be symbolic of Uganda. The government had crushed the country, the people, and then vanished, and left a population steeped in lawlessness, chaos, and poverty. Each time we hired a driver to go on an excursion, they were manic about getting on the road back to Kampala by midafternoon ­ so as not to be driving after dark.

They feared being robbed, even killed on the road. Nobody would drive after dark. "You'd have to be crazy," said one driver.

The bank in our hotel was robbed one morning, just as I was walking toward it. There were power failures constantly. No medical supplies, even in the hospitals. People were crammed throughout the corridors of the hospitals, waiting, maybe for days, to get any attention, and even then, what attention? What medication they had was poor quality, often too strong, unspecific, and ineffective. People bought prescription medications from little shacks called drugstores that had smuggled them from God knows where. Deaths were not counted, except maybe at some hospitals, but many people just died in the villages. It was not known how many people had died in any given year, much less what the cause of death had been. To try to make sense out of AIDS, with HIV tests and T­cell counts and clinical case definitions, in this chaos seemed hopeless; and to saddle them with this unproven, unwarranted death sentence and terror seemed almost cruel. The first thing we heard upon arriving in Mombasa, Kenya, was from Joan's friend who picked us up at the train station. "Terrible," he said, shaking his head. "I just heard on the radio that a young woman jumped to her death from a hospital roof because she got the results of her test and she was HIV­positive."

Seated next to us on the plane from Kenya back to London was a British gentleman who had been working with a water restoration program in Kenya for six months.

"That must have been interesting," I said. "Is the water really bad in Kenya?"

"Oh, my God," he said. "You should have seen it when we got there. People were so sick."

"Sick?" we said.

"Mmm. They had the most atrocious diarrhea and vomiting and abdominal pains."

I stared at him.

"How long had this been going on," I asked.

"Oh, about ten years."

"And did the symptoms subside when you cleaned the water?"

"Oh, absolutely."

Joan and I looked at each other, sighed and ordered a drink. Beneath us, Africa was disappearing, as we climbed higher and higher into the sky. *