Plague Years

by Ross A. Slotten, MD

  In 1993 Google didn’t exist, nor did Amazon.com. Research could be cumbersome: I had to comb libraries for relevant publications and search bookstore catalogs for books about Namibia. There wasn’t much. And for reasons that were never made clear to me by the heads of public health clinics or hospital directors I solicited, I would not be allowed to examine patients or visit clinics in Namibia, which would have added a human dimension to my research. That disappointed me because I was a doctor, not a journalist, spy or politician.

  Early on I realized that I would have to infer the nature of the epidemic there from statistics gathered in countries that encircled Namibia—Angola, Zambia, Zimbabwe, Botswana, and South Africa, where the epidemic raged. An observer in South Africa prophesied that there “AIDS will knock the bottom out of health budgets.” Already many hospital beds in other sub-Saharan countries were occupied by patients with HIV-related problems. For example, at the University Teaching Hospital in Lusaka, Zambia, people with AIDS occupied 40–60 percent of the beds, not much different from American cities with sizable gay populations. In Botswana, just under half of hospitalized patients with tuberculosis were HIV positive. There was no reason for me to expect the situation to be different in Namibia.

  Namibia had become a sovereign nation only three years earlier, in March 1990, after seventy years of racially separatist South African domination. Before that it had been a German colony for thirty years. A small urban white population still spoke German as their primary language. Since independence, Namibia had become a multiparty democracy.

  Overall, Namibia is arid. The parched landscape, rugged topography, and quality of light surrounding its capital, Windhoek, reminded me of northern New Mexico. The sky was cloudless and the air pollution-free. Scrubby plants sprouted from the sandy, iron-stained soil. The most distinctive geological features were inselbergs, which resembled islands of weathered crags. At sunset the earth turned a kaleidoscope of colors from the fine dust in the atmosphere. It looked like nothing could flourish here, not even AIDS.

  Yet Windhoek was picturesque in a way that seemed more European than African. It did not conjure up the American perceptions of Africa as poor, dependent, and even barbaric. Rather, it brimmed with busy shops, and well-dressed people both white and black crowded the streets. The tidiness and prosperity of Windhoek impressed me, until I learned that 70 percent of Namibia’s people lived in impoverished rural areas and 75 percent of the wealth was controlled by only 5 percent of the people. Trying to expand its tourism industry, Namibia had opened itself to Western journalists. Only a week before leaving Chicago, I read two articles about Namibia in the New York Times, one about the disappearance of the San culture (Bushmen) in the Caprivi Strip, a panhandle stretching northeast to Zimbabwe; another about an American couple who’d moved to Namibia to save the dwindling cheetah population.

  But to my chagrin, Namibia was a homophobic country. When Gavin and I arrived at our hotel, the clerk ignored our request for a single room and consigned us to separate but adjacent rooms. We slept in one bed anyway, locking the door to prevent accidental entry of a maid. We messed up the bed in the other room and bathroom, strategically placing pubic hairs in both to give the illusion that we slept and bathed separately. During our travels there our guide, a white Namibian, made sure that Gavin and I didn’t share a tent. When one of our fellow travelers, an eccentric elderly American woman Peace Corps volunteer, remarked to our guide—who helped set up camp, cook our food, and ensure our comfort—that he would make a good “househusband,” he replied with a limp wrist. Another white Namibian in the group added, “We don’t have any of those here. They’re all in San Francisco.” Although it wasn’t necessarily dangerous to be a gay traveler in Namibia, gays weren’t welcome—though this could be true in the United States too. Acceptance and tolerance were relative concepts, codified in constitutions that guaranteed equal rights for all citizens but ignored in practice.

  My first research task was to meet with Dr. Markus Goraseb, the AIDS Programme director. I knew nothing about his background or who employed him. I’d drawn up a list of forty questions to help me understand the recent social and political changes that had contributed to the spread of the AIDS virus there. I was searching for solid statistics. In light of the lack of discussion in the medical literature, I had little choice but to rely on my Namibian sources if I was to learn anything substantive. But prior to my arrival they hadn’t been forthcoming. A fax to the AIDS Programme the week before had gone unanswered. My only lead had come from the World Bank, where my contact sent me publications about health problems and economic indicators of Namibia, although she cautioned me not to mention the statistics to anyone since they had not yet been released to the Namibian government. She also recommended that I visit the UNICEF office in Windhoek, which was likely to have statistics on a variety of health factors. It was she who had given me Dr. Goraseb’s name.

  From my hotel, I hailed a cab but had no idea where I was going. The taxi driver dropped me off somewhere and pointed me toward the Christ Lutheran Church, a local landmark, by the Parliament building. I walked up a slight incline but then didn’t know where to go. I found my way to the Ministry of Agriculture, where a thin, affable older black man stood by the entrance. I asked him for directions to the public hospital.

  “Oh no, no, sir. It’s very far away, all the way across town,” he said in accented English. My heart sank. He said it was too far to walk, but I wasn’t sure I believed him. I asked for a telephone and he led me inside, to the minister’s office. A pleasant white secretary confirmed the man’s directions, which made me feel sheepish for distrusting him. Thanking them both, I found another taxi. The driver needed more gas, which made me nervous because already I was at risk of arriving late for my appointment, but nevertheless we soon arrived at a rambling, austere series of low-lying buildings.

  It took three different people to direct me to Dr. Goraseb’s office. I could tell I was close because there were posters on the wall addressing the AIDS problem. Then, to my chagrin, no one knew where Dr. Goraseb was or when he was due to arrive. I wondered if I’d wasted my time. In the interim, a secretary directed me to a Dr. Boadu, a short, stocky man dressed informally in a short-sleeved shirt. Caught off guard, he asked for my credentials before promising to talk to me in five minutes. He led me to a conference room adjacent to his office where I could wait for him. That room looked out onto a tidy courtyard landscaped with various shrubs and flowers. On a large pad of paper on an easel, someone had scribbled something like “AIDS is Yth,” a picture of a face, and the word “ignorance.” I wasn’t sure what it meant, but it presumably addressed the fact that the ignorance of young people drove the epidemic in Namibia. There were also a few posters, among them an advertisement for World Health Day and a cartoon of a man and woman discussing safe sex. I discovered a library of sorts, a set of pigeonholes with pamphlets on AIDS and HIV. Some pamphlets originated from the CDC, WHO, or other governmental sources in Africa, all outlining policies or recommending policies or approaches to the AIDS problem.

  I waited about thirty minutes. I could hear Dr. Boadu speaking to various people. Eventually he entered with a middle-aged female secretary and a handsome young black man sporting rimless spectacles who introduced himself as Tsali. Currently a student at Denison University in Ohio who hoped to go to medical school, Tsali had an interest in epidemiology and was researching health problems in Namibia. He’d only been in Namibia for a few weeks. It had been six years since his last visit to his homeland.

  Speaking at a rapid clip, Dr. Boadu gave us a history of the AIDS problem in Namibia, repeating what I’d gleaned from the pamphlets. Thus far 4,400 cases had been reported, but he emphasized that these “stats” were meaningless. Who knew how many? he said. Diagnoses were made using the WHO-Bangui definition of AIDS: weight loss greater than 10 percent of baseline body weight; chronic diarrhea for more than a month; prolonged fever for more than a month; and other physical signs of immune s
uppression in the absence of another known cause. He couldn’t tell me what major indicator diseases in Namibia were, because AIDS was still a “clinical” diagnosis—based on signs and symptoms rather than on laboratory tests, which were often too expensive to run.

  He talked about Namibia’s plans and goals, which remained notional because funds were short, though various nongovernmental organizations and government agencies had pledged financial support. Because of limitations in access and cost, HIV testing was not widespread, he said, but it was done for prenatal care. However, since many people didn’t go to hospitals for their medical care, he had little hard data.

  Dr. Boadu didn’t seem to harbor the common prejudice in Africa about the homosexual transmission of HIV in the West, nor did he dismiss the role of traditional healers in Namibian health care. He himself was Ghanaian, a fact that implied that Namibia lacked the medical personnel or expertise to confront the epidemic, which might have explained why I wasn’t allowed to see patients. Because he was in a great hurry, I never saw his credentials. He left us in the hands of the secretary, who knew a good deal more about HIV/AIDS than I expected. She happily agreed to make copies of some documents for me.

  Tsali drove me back to the center of town. He told me that he had two brothers, one also in the United States studying law, the other a ten-year-old who was at home with their parents. His family had befriended the American couple helping to save the cheetah. Although he didn’t acknowledge it, his family belonged to the ruling elite. His father held an important job, the nature of which was not revealed to me.

  Tsali was very bright and clear-headed. He was determined to become a doctor and return to help his country. He told me that he intended to remain in Africa until August before returning to the US. I promised to send him some articles about health problems in Namibia, but I hesitated to extend an invitation to Chicago because I didn’t know his attitude toward gay people. Perhaps he was also gay. It was hard to tell. Sometimes in foreign countries I thought all the men were gay. They were far more affectionate with their friends, wore better clothes and hipper hairstyles, and rarely walked with a swagger like young men did in the United States. But American gay men emulated Europeans in style and manner, not vice versa.

  Back at the hotel, I collected Gavin and we mistakenly hunted for the UNICEF office in the Ministry of Justice. We wandered down a short, dim hallway lined with posters, mainly of wildlife. A man at a desk called out to us, his voice echoing. He had no idea about UNICEF, but he was kind enough to find out and give us directions. As we left, we noticed an anti-AIDS poster sponsored by an Islamic group, which blasted the West for telling people to have fun and be gay and to have lots of sex. It also condemned condoms and advocated abstinence. Gavin and I snickered at its clumsy cartoons. The posters would have had negligible effect in Namibia itself, because less than 1 percent of the population there was Muslim.

  At UNICEF headquarters a clerk handed us blue badges, which we each clipped onto a lapel. Gavin waited in the lobby while a friendly secretary led me to the office of the medical director. Although I’d made an appointment weeks in advance and traveled thousands of miles to meet with him, he, like Dr. Goraseb, wasn’t available. Sensing my disappointment, his secretary allowed me to peruse various documents in a little library. Delighted to find so many relevant publications, I quickly forgot the slight. With permission, I started copying one of the documents but quickly realized I’d never finish, given my time constraints. I was able to cajole a young woman working in the library to make copies of three of them, each less than twenty-five pages long. Then we sat and talked about my project, which interested her.

  She spoke about the difficulties of educating Namibians about AIDS. AIDS was a disease of young people, she said. When it came to sex, there was no parental guidance. The men, like men all over the world, gay or straight, didn’t want to wear condoms. Well educated and fairly sophisticated, she seemed to enjoy chatting about her country, even about such morbid subjects as AIDS. In fact, after a while I wondered if I’d be able to leave. Finally I managed to thank her for her help and kindness, return to the lobby, and drag Gavin, whose patience had been stretched to a tether, to another bookstore in search of a book she had recommended.

  We spent the next five days traveling throughout the country by air and Land Rover, encountering herds of elephants, various antelopes, zebras, and giraffe but no lions or big cats. For the most part we had the highway to ourselves. When a vehicle sped by, it was most often a Mercedes Benz, BMW, or Audi with white driver and occupants. Now and then a truck roared past heading for I knew not where, the driver invariably black. I wondered if the trucks left Namibia for Botswana, Zambia, or places even farther afield. I needed to find out, because in Africa AIDS spread along truck routes. Trucks there were the modern equivalents of caravans traversing the Silk Road and flotillas invading Asia and the Americas, conveying material goods, religion, and disease from one part of the globe to another.

  Near a town called Otavi we stopped at a rundown roadside filling station. I glimpsed a few black men loitering outside the toilets. A black woman in a skimpy dress with shoulder straps and a low neckline teased them. It was clear that she was a prostitute and the filling station an informal truck stop. Here was a vivid example of how an epidemic spreads. An apparently healthy woman (or man) and apparently clear water differ little when it comes to disease transmission. People drink at both wells without hesitation. If a virus or bacterium loomed as large as monsters, who wouldn’t flee? But viruses and bacteria are invisible to the naked eye. It takes imagination, experience, and a belief in the discoveries of modern science to fear infectious agents, which we can’t see. To many people in the world the idea of a human being as a vector of a lethal disease seems incomprehensible. It’s as if a gas chamber at Auschwitz masqueraded as a cleansing shower for the unsuspecting victims who were directed there to clean up immediately after their arrival.

  Back in Windhoek, we parked our van on a major thoroughfare. We’d been cautioned about the prevalence of theft in the city, and the barbed wire and broken bottles atop the walled enclaves along our trip attested to a high rate of burglaries. If potential thieves peered through the darkened windows of our vehicle, they could see our luggage, which included books, pamphlets, and other important research documents. I didn’t care about the clothes or toiletries, which could be replaced, but the books and papers were irreplaceable. Gavin told me to stop worrying. We dined at a café on the second floor of a building from which we could see the van. Although Gavin thought I was being paranoid, he promised not to let the van out of his sight.

  The café bustled with activity. Most of the customers were tourists or expats, and we caught bits of their conversation. A group of American women detailed their sexual exploits in San Diego. Thank God they weren’t gay men, I thought, or they might have freaked out about their health instead. By coincidence, the man who’d organized one of our tours dined nearby with his wife. As we thanked him for a wonderful trip, Gavin’s attention suddenly returned to the van, which two suspicious-looking men were scoping out. Without excusing himself, he dashed out of the restaurant, while I continued to chat with the couple and tried not to appear nervous. After shaking their hands, I paid our bill and left in a rush.

  The street teemed with people and was blocked off because of some sort of charity parade that the country’s president planned to attend. I seemed to be the only person moving in the direction of our car. By the time I reached the car, after what seemed to be an eternity because of my anxiety, Gavin fumed in the driver’s seat, gripping the steering wheel. The two men had been looking to break in, but when he shooed them, they wouldn’t leave until he became enraged. He admitted to being unnerved because they could have been armed with guns or knives, though violent crime in Windhoek was rare.

  The incident hardly marred the trip. As we drove to the distant airport to catch our flight to Berlin, we traveled a lonely highway that followed the contours of the
scrubby rolling hills and talked about what it might be like to live in Namibia working for some nongovernmental medical organization. We wouldn’t have brought anything valuable, we agreed. Although Windhoek was still quaint, belying the quaintness were the poverty and misery of the majority of the population. In those impoverished townships, with their rudimentary healthcare services and widespread ignorance about safe sex practices, an epidemic like AIDS would be unstoppable.

  : 12 :

  AIDS in Berlin (1993)

  We arrived in Berlin on a Sunday morning in the first week of June 1993. Most of the people flying in then were heading to the AIDS conference. It was a truly international array of visitors from the Americas, Asia, Africa, and other parts of Europe. I admit that I wasn’t excited about being in Berlin, though Gavin was. Because of Hitler and the Holocaust, Germany ranked near the bottom of places I wanted to explore. I had come to attend the conference, not to immerse myself in the country’s history and culture or mingle with its inhabitants.

  This was my fourth international AIDS conference, after Paris in 1986, San Francisco in 1990, and Florence in 1991. Although conferences had been held in the United States, no future ones were planned there because of its restrictive and regressive immigration policies: HIV-positive individuals from foreign countries were forbidden to enter. This outraged the sponsors of the annual event, the International AIDS Society and the World Health Organization. I was outraged too, but I wasn’t an activist. I didn’t fire off letters in protest or march with ACT-UP. Instead I grumbled about its outrageousness to patients and colleagues, like an armchair politician. President Barack Obama finally rescinded that policy in 2010.

  Our hotel was in the former East Berlin, which had been liberated from the Soviet sphere only four years earlier. After showering and changing, we set out for the International Conference Center in West Berlin to register for the week’s events. As we left the hotel, we paused to admire a grand building with a frieze on its architrave and a blackened dome adorned with bronze emblems that gleamed in the sunlight. The rest of the neighborhood was in the throes of gentrification, its streets shredded to make way for modern sewers and buildings cocooned in various stages of restoration. In five to ten years the entire area would be unrecognizable, the grime replaced with glitz. Already fancy boutiques had moved in. There was even a Mercedes-Benz dealership. As we took the elevated train, the amount of graffiti I could see appalled me. Gibberish and hideous slashes of paint covered every available surface and spared no building. I wondered why the municipal government and Berlin’s citizens tolerated such brazen defacement of public and private property. Its ubiquity disturbed me, as if chaos were triumphing over order. Like most doctors, I prefer order.