The Shackled Continent

by Robert Guest

  Why AIDS is hard to curb

  The best hope for halting AIDS would be a cheap vaccine. Scientists are trying to find one, but it could take years. HIV mutates rapidly, so it is hard to teach the body’s immune system to recognize and attack it. In the short term, the only way to curb the epidemic in Africa is to persuade people to shun risky sex. This is also hard, for several reasons.

  Sex is fun. And many people feel that condoms make it less so. Zimbabweans ask: “Would you eat a sweet with the wrapper on?”

  Talking about sex is often taboo. Many traditional parents think it shameful to discuss the subject with their children. Some conspiracy theorists even argue that the whole hoo-ha about AIDS is a bizarre plot to make blacks appear immoral. When my wife’s book on AIDS orphans was published, a South African reviewer accused her of trying “to advance a racist ideology that portrays African people as promiscuous and reckless” simply because she repeated the conventional view that HIV originated in Africa.8

  Myths abound. Some young African women believe that without regular infusions of sperm, they will not grow up to be beautiful. Ugandan men have been known to use this myth to seduce schoolgirls. In much of southern Africa, HIV-infected men believe that they can cleanse themselves of the virus by passing it on to a virgin. This is an old myth. Nineteenth-century Brazilian slave-owners thought they could cure themselves of syphilis in the same way. The result is the same in Africa now as it was on Amazonian rubber plantations a century and a half ago.

  Poverty. Those who cannot afford television find other ways of passing the evening. Poor people often cannot afford antibiotics to treat other sexually transmitted diseases (STDs). STDs can open sores on the genitals, which provide easy openings for HIV to enter a new host.

  Migration. When people are mobile, the virus spreads. Migrant traders and bricklayers flock to South Africa, where wages are much higher than in neighboring countries. Gold miners spend eleven months of the year apart from their families, often living in single-sex dormitories surrounded by prostitutes. Living with a one in forty chance of being killed in a rockfall, they are inured to risk. When they go home for Christmas, they often infect their wives.

  War. Refugees spread HIV as they flee. Soldiers, with their regular wages and disdain for risk, are more likely to be infected than civilians. They are also able, in the chaos of battle, to rape with impunity. A friend and colleague of mine, James Astill, the Economist’s former Nairobi correspondent, spent time with the Mai-Mai, a ragged militia band notorious for gang-raping peasant women in eastern Congo. They offered him a chance to ingest a charm they said would make him invulnerable: a paste made from the severed penises of their enemies, the Rwandan soldiers who had invaded Congo. The spell worked, they said, if you opened a cut in your arm and rubbed in the paste. They all used the same rusty knife. James said thanks but no thanks.

  Sexism. Many African women find it hard to ask their partners to use condoms. In one survey in Zambia, less than a quarter of women believed they had the right to refuse sex with their husbands even if they knew he was unfaithful and HIV-positive. And only one in ten thought she could ask him to use a condom in this situation. Women who try to insist on condom use risk being punched. In two districts in Uganda, 41 percent of men admitted to researchers that they beat their partners. Another study found that sexual violence was “widespread” in South African schools.9 Forced sex is an unusually effective means of HIV transmission because the victim usually bleeds.

  Alcohol. African beers are, by and large, delicious. Drunken lovers are less likely to remember to use condoms. A survey of women in an area frequented by sex workers in Carletonville, a mining town in South Africa, found that 65 percent of those who drank were HIV-positive, compared with only 30 percent of non-drinkers.

  Finally, there is the question of foreskins. Several studies suggest that African men who are circumcised before puberty are less likely to contract HIV. Even allowing for cultural differences between groups that snip and groups that don’t, circumcision appears to offer limited protection. Possibly this is because the tip of the penis grows tougher if not cushioned by a foreskin. Unfortunately, the discovery that circumcision makes sex safer has led some people to believe that it makes sex safe and so they neglect to use condoms.

  None of these problems is unique to Africa. But nowhere else has them all in such abundance. Of all the factors driving the epidemic, promiscuity is the hardest to discuss without upsetting people. Sexual mores clearly differ between cultures. Premarital sex carries less of a social stigma in Holland or Japan than in, say, Saudi Arabia. But it is hard to determine how promiscuous societies are, because people lie about sex. Ask a young British man how many women he has slept with, and he may exaggerate the number to make himself seem more virile. Or, if he is religious, he may downplay it.

  We don’t know how much sex Africans have, or how many partners they have it with. But a couple of generalizations are possible. First, many sub-Saharan societies are relatively permissive. Polygamy is quite common. Sex may not be discussed openly, but many men flaunt mistresses, and unmarried urban women do not seem embarrassed when a boyfriend stays the night.

  What may be as important as the number of partners is what is called the “pattern of sexual networking.” Consider the way AIDS spreads in Thailand. Thai women are expected to be virgins when they marry, but men can fool around without being thought immoral. Extramarital sex usually means a trip to a brothel. If a Thai man contracts HIV, it will probably be from a prostitute. He may then pass the virus on to his wife, who may infect her unborn child. The family is destroyed. But the chain usually stops there.

  In Africa, the pattern is often different. A married man may have sex with prostitutes, but he may also have casual affairs with teenage girls. Girls who contract HIV from a “sugar daddy” often survive long enough to get married and pass the virus on to their husbands. Those husbands may then have affairs with younger women. And so on. Sex between people of different generations helps keep the virus circulating.

  In eastern and southern Africa, HIV prevalence is far higher among teenage girls than boys. The only plausible explanation is that young girls are having sex with older men who have been sexually active for long enough to contract the virus.10 Anecdotal evidence is plentiful, too. Anyone standing outside a high-school gate in Kenya or Zambia will sooner or later see girls get into cars with middle-aged men who are not their fathers. These girls then usually go on to marry men of approximately their own age.

  How to fight it

  There is hope. Two African countries – Uganda and Senegal – have shown that AIDS can be curbed. Uganda’s example is especially heartening because it shows what can be done with almost no money.

  Uganda is poor by any standards. When Yoweri Museveni seized power in 1986, the country was one of the poorest and most violent in the world. In the 1970s and 80s, under the tyrants Milton Obote and Idi Amin, perhaps 800,000 Ugandans were shot or bludgeoned to death or starved when soldiers stole their harvests. Average annual income in Uganda was a meagre $150 or so. Half of the population was illiterate. Years of chaos and civil war had allowed HIV to spread unchecked, although no one knew this at the time because the doctors who might have tested people had mostly fled the country.

  President Museveni has his faults, but he quickly recognized the threat that AIDS posed. In 1984, he recalls, while listening to the BBC he heard an Italian professor talking about the situation in Zambia. He explained that HIV could be spread through heterosexual as well as homosexual intercourse. “I thought this was very dangerous, given the habits of our people – it would finish them,” Museveni told the Times. Shortly afterward, he sent sixty of his soldiers to train in Cuba, where the government tested them for HIV. Museveni was shocked to discover that eighteen of them were infected.11

  He acted swiftly, forcing every government department to draw up a plan suggesting what it could do to tackle AIDS. The budget was tiny, but they coped. Accurate surveys
of sexual behavior were conducted for only $20,000–30,000 each. Posters discouraging risky sex were erected by busy roads. A rise in literacy, from 51 percent in 1980 to 65 percent in 1998, allowed more Ugandans to read them.12

  To fill the gaps that the state could not, non-governmental organizations (NGOs) were given free rein to do whatever it took to educate people about HIV. Scores of charities, many foreign-financed, took up the challenge. I visited a few, including the Straight Talk Foundation, which publishes newsletters that teach adolescents and pre-teens about sex in a straightforward, unpreachy way. Rather than seeking to scold or scare, they probe the complexities of puberty, relationships, and sex.

  Talking about relationships is often more important than talking about the mechanics of how HIV is transmitted. For many young people, the problem is not that they are ignorant about AIDS but that they are unsure how to deal with romantic situations. So Straight Talk’s volunteers do not merely issue warnings; they run romantic role-playing sessions in Ugandan schools. These help girls learn how to insist on condoms, for example, or how to persuade their boyfriends that they are not yet ready for sex. Convincing teenage boys that remaining a virgin is cool has proven more difficult. One reason, according to Cathy Watson, the foundation’s director, is the popularity of pirated Western porn videos, which some viewers think reflect the way rich and sophisticated people behave.

  Straight Talk’s newsletters, handed out free in schools, cover everything from nocturnal emissions to what to do if raped. Visiting AIDS workers from Zimbabwe and South Africa asked Watson how she won government permission to distribute such explicit material. They were astonished to hear that she had not felt the need to ask.

  The climate of free debate has led young Ugandans to delay losing their virginity, to have fewer partners, and to use more condoms. Among fifteen-year-old girls, the proportion who said they had never had sex rose from 20 percent in 1989 to 50 percent in 1995. Between 1994 and 1997, the proportion of teenage girls who reported ever having used a condom tripled.

  And the epidemic was rolled back. Between 1992 and 2002, HIV prevalence among women attending urban antenatal clinics fell from almost 30 percent to about 5 percent.13

  If Uganda shows how a poor country can roll back an epidemic that is already raging, Senegal shows how to stop it taking off in the first place. West of the Sahara, this mainly Muslim country is fortunate to be several thousand miles from HIV’s origin in central Africa. In the mid-1980s, when other parts of the continent were already blighted, Senegal was still relatively HIV-free. In concert with NGOs and the media, the government set up a national AIDS-control program to keep it that way.

  In Senegal’s brothels, which had been regulated since the 1970s, condom use was firmly encouraged. The country’s blood supply was screened early and effectively. Vigorous education resulted in 95 percent of Senegalese adults knowing how to avoid the virus. Condom sales jumped from 800,000 in 1988 to 7 million in 1997. Senegalese levels of infection have remained stable and low for a decade – at under 2 percent.

  How to dither and die

  Other governments have been less alert. South Africa, for example, has resources and skills that Uganda and Senegal can only marvel at. But AIDS-prevention efforts in South Africa have been, to put it kindly, confused.

  The government had plenty of warning. AIDS came late to South Africa. In 1990, it was a relatively small problem. Fewer than 1 percent of South African women in antenatal clinics tested positive for HIV that year. The African National Congress had ample opportunity to observe the epidemic devastating South Africa’s northern neighbors. But perhaps because negotiating an end to apartheid was such an all-consuming task, they did not pay it much attention.

  During its first five years in government, 1994–9, the party did practically nothing. Nelson Mandela, South Africa’s first black president, rarely mentioned the disease. When I arrived in South Africa in 1998, I was amazed to see no anti-AIDS posters at all. In my first year in the country the only two I noticed were both in a small office used by the United Nations anti-AIDS program in Pretoria. The only senior member of Mandela’s government who tried to do much about AIDS was the health minister, Nkosazana Dlamini-Zuma. Her contribution was to sponsor a costly flop of an anti-AIDS musical, to promote a toxic “cure” based on an industrial solvent, and to purge South Africa’s drug-control agency when its members objected.

  By 2002, HIV prevalence had risen fifteenfold, making South Africa the country with the most infected people anywhere in the world. Roughly 4.5 million South Africans carried the virus.14 By way of comparison, this is more than 200 times the number of people who died in political violence during the turbulent decade before liberation.

  Many people hoped that Thabo Mbeki, who succeeded Nelson Mandela as president in 1999, would take the catastrophe more seriously. He did, but not in the way anyone expected. After long nights researching the subject on the Internet, he began to question whether HIV really caused AIDS. He appointed a panel of experts to look into the matter, including some American AIDS “dissidents” (who denied that HIV caused AIDS) and excluding anyone from African countries that had actually succeeded in tackling the epidemic. His health minister, Manto Tshabalala-Msimang, circulated chapters from a book claiming that HIV was concocted by a secret organization called the Illuminati as part of a conspiracy to wipe out homosexuals, blacks, and Hispanics. All this nonsense baffled ordinary South Africans. Some thought that their president was telling them that AIDS didn’t exist and concluded that it was therefore OK not to wear condoms.

  Despite all the strange goings-on in the presidential mansion, many young South Africans seem to have realized that unprotected sex is risky. The media have treated the issue far more responsibly than the government has. NGOs have paid for a lot of gaudy posters on city billboards and pamphlets suggesting how to have fun without penetration. The main targets of these warnings are teenagers. Those who are not yet having sex are rarely infected. If campaigners can catch them while they are still virgins and persuade them either to stay that way or to use condoms, a generation could be saved. It might yet be. A survey of young women in 1998 found that only 16 percent said they had used a condom the last time they had sex with someone they weren’t married to. By 2000, another survey found that a more encouraging 55 percent of young South Africans said they always used condoms. One hopes most were telling the truth.

  Thabo Mbeki attracted so much criticism for his attitude to AIDS that he eventually said he would “withdraw” from the debate. His government’s policies then started to improve. In November 2003, the South African government unveiled a serious, well-funded, and long-term plan for treating its sick citizens with the anti-retroviral drugs that have worked so well in rich countries – which would make no sense if HIV did not cause AIDS. Such drugs are not a solution; they suppress the disease, but they do not cure it. But if the plan is competently implemented, they should keep millions of South Africans alive long enough to raise their children to adulthood. Other African countries still find it hard to afford such drugs, but the prices are falling fast, and foreign donors are increasingly willing to pay for them.

  A speck of hope

  Looking at the carnage AIDS has wrought in Africa, it is easy to despair. Some Africans do. Chenjerai Hove, a Zimbabwean novelist, put it like this: “Since our women dress to kill, we are all going to die.”15 But if the sexual urge is basic, so is the will to live. If enough Africans wake up to the fact that unprotected sex is Russian roulette, Hove could yet be proved wrong.

  5. THE SON OF A SNAKE IS A SNAKE

  Why tribe and state should separate

  Nestor Nebigira fell in love. But because he fell in love with the wrong woman, tribal politics ruined both their lives and left their children forever at risk of being murdered.

  Nebigira is a Hutu married to a member of the Tutsi tribe. I met him in a refugee camp in Tanzania, where he was selling matches, combs, and other essentials to his fellow fugitives. I
t was hardly a lucrative business: refugees have little money, and there was, in any case, only enough room for one customer at a time to browse in Nebigira’s tiny shop. When I spoke to him he had no customers at all; a storm was pounding the camp, and the other refugees were sheltering in their huts.

  “I was a successful businessman once,” he told me. Born in Burundi, he lived well until 1994, when, after months of ethnic massacres, he decided that there was nowhere in his homeland safe for a “mixed” family.

  He was terrified that Tutsi soldiers might kill him, or that angry Hutus might kill his wife, or that zealots of either hue might kill the whole family for not being bigoted enough. So they packed as many possessions as they could carry and fled to Zaire, as Congo was then called. I gulped when he told me this. You have to be desperate to seek refuge in Congo. But that was not the end of the story. After two years, another war forced them to flee again. This time, they took a ferry across Lake Tanganyika and ended up in the camp where I met Nebigira, standing on the mud floor of his comb shop.

  Burundi has roughly the same ethnic make-up as its more notorious equatorial twin, Rwanda. The Hutus form a large majority of the population of both countries, while the Tutsis are a minority. Burundi was ruled by a succession of Tutsi despots from independence until 1993, when a brief experiment with democracy went wrong. The reigning Tutsi strongman, Pierre Buyoya, called a free-ish election and then stood aside for the Hutu victor, Melchior Ndadaye. President Ndadaye lasted for less than five months before he was kidnapped and murdered by Tutsi army officers. Hutu mobs retaliated by killing their Tutsi neighbors, which in turn prompted the Tutsi-dominated army to seize power. In the ensuing civil war, 300,000 people died and 1.2 million fled their homes. In other words, Nebigira’s tale is not unusual.