The New York Review Abroad

by Robert B. Silvers

  These efforts have been reasonably successful. In 1992, 16 percent of all adults in the country were HIV-positive, but by 1996, only 8 percent were. The proportion of HIV-positive people in Uganda has fallen far more slowly since 1996, and there were even indications that the infection rates rose slightly in rural areas in 1999.4 But even if the decline in HIV prevalence has slowed, Uganda’s relative success in dealing with HIV is unique in sub-Saharan Africa, and international health experts from the UN and other agencies have claimed that Uganda should be seen as a model for other countries.

  However, questions have been raised about whether the fall in the number of HIV-positive people in Uganda really indicates that the epidemic is waning. To understand this, it helps to know the difference between what epidemiologists call “prevalence” and “incidence.” Prevalence refers to the number of infected people in a population, while incidence refers to the rate at which people become infected. In an epidemic, it is incidence that must be reduced. Prevalence falls later, as people either recover or, in the case of HIV, die from AIDS. Incidence is much harder to measure than prevalence, and health departments seldom do it routinely. But epidemiologists conducting smaller studies of particular Ugandan populations have shown that even when prevalence is falling, incidence may still be high, or even rising. In fact, while some regions of Uganda have seen a fall in HIV incidence during the 1990s, others have seen little change.5

  The Ugandan HIV epidemic probably occurred in two phases, and this could explain why incidence may be stable or even rising, even though prevalence is falling. The first phase occurred during the war and its aftermath in the 1980s. At the time, many cases of HIV infection probably resulted from what the authors of a recent study politely refer to as “one-off” sexual encounters.6 Rape and prostitution, in particular, are well known to escalate during war. For example, it is estimated that virtually every woman who survived the Rwandan genocide was raped; at least 20,000 women were raped during the Bosnian war; and at least 250,000 were raped during the 1971 war of independence in Bangladesh. I could find no statistics on rape in Uganda during the civil war in the 1980s, but it is believed to have been very common.

  At the time, Ugandan women also saw their families and livelihoods destroyed, and some were forced to exchange sexual favors to provide basic needs for themselves and their children. Since HIV prevalence rates among soldiers in East Africa tend to be very high, it is plausible that HIV first began to spread quickly in Uganda during the turbulent early 1980s. The second phase of the HIV epidemic in Uganda occurred during the relative peace of the 1990s. Today, most HIV transmission actually takes place in longer-term relationships. Indeed, those most at risk of HIV infection in Uganda now are married women who have sex only with their husbands.

  The hypothesis that the HIV epidemic in Uganda occurred in two phases implies that HIV prevalence may have fallen in the 1990s because many people infected during the war in the 1980s died of AIDS. Nevertheless, HIV incidence rates during peacetime may still be quite high, although they are probably much lower than they were during the war.

  2.

  For more than a decade, charities and health ministries in many sub-Saharan African countries have established numerous HIV prevention programs like those in Uganda, but the results have been mixed. HIV prevention programs in Africa have been far less successful than those for gay men in Europe and the United States, and there has been much speculation about why.7 Some programs have been moderately successful, but the epidemic is far from over anywhere in East and Southern Africa, including in Uganda.

  When I was in Uganda in 1995, I myself wondered about the effectiveness of prevention programs. By then, it seemed clear that the vaccine I was studying did not work, and I knew it would be a decade, at the very least, before scientists found one that would protect people from HIV. But Uganda could not wait for a vaccine. At the time, one in five adults in Kampala was HIV-positive, and the virus was spreading along trade routes into the countryside and up into the poor and isolated villages in the north. The AIDS epidemic has concentrated attention on the circumstances in people’s lives that increase the likelihood of unsafe sex, even when people know they should be careful. These circumstances are still poorly understood, but at least two schools of thought have emerged. Either people’s beliefs about condoms, fertility, and disease prevent them from practicing safe sex or they are constrained by larger social conditions in their lives, such as poverty and unemployment, that result in a kind of resignation, a feeling that HIV infection is inevitable, and beyond one’s power to prevent.8

  Every African community has a medicine man or woman to whom an estimated 80 percent of African people turn in distress. These healers are part quack doctor, part psychiatrist, and through their rituals, stories, and medicine they preserve and hand down traditional African culture and beliefs. Perhaps it is through these healers, I thought, that I could understand the mysterious, persistent spread of HIV.

  I knew of a charity that was working to train Ugandan traditional healers to become AIDS prevention counselors and I spent a few months working with them, tramping through villages and riding on bicycle taxis into the Ugandan countryside. I met a healer who cured his patients of diseases of the mind and body by placing live chickens on their heads, and another who did it by massaging the soles of their feet. Yet another inspected drops of his patients’ saliva on the surface of a mirror. For many healers, the cure was the sacrifice of a white chicken or, in more serious cases, a goat. The healers told me how the human race had been created when the sun and the moon gave birth to the stars, and then to the earth and the gods. There were gods for love, jealousy, and malaria, but there was no god for AIDS. All of the healers knew about AIDS, but they said they didn’t know where it came from, or how it could be cured. Many of them went to the training sessions the charity conducted, and learned to demonstrate how condoms are worn, and how to recognize when a patient probably has AIDS and should go to the hospital.

  Once I went to the initiation ceremony of a traditional healer named Matthew. About thirty people gathered in an old barn in a village near Kampala. The ceremony lasted until dawn, and during the night different men and women fell one by one into mystical trances in which they reenacted the founding myths of the Buganda people, the largest tribe in the country.

  During the daytime, Matthew was an accountant for an auto repair shop in Kampala, or he would have been if the company’s owner had not emptied its bank account and gone to Kenya. Matthew still sat in his office all day reading newspapers and waiting for people to ask him to do their accounts. On the street where Matthew worked you could buy almost anything: furniture, chicken coops, spare parts for cars, machine tools, jerry-built appliances of all kinds. Pale green trucks with flimsy sheet-metal frames stood in the middle of the street piled high with bananas, foam rubber mattresses, chickens crammed in their cages, their feathers raining everywhere. The businesses spilled onto the sidewalk of broken paving stones, where women with enormous bundles on their heads and dusty, barefoot workers dressed in rags and stray goats and chickens mingled with the chaotic traffic in the street.

  Matthew and I had an appointment, but he was not around. The workmen in the shop next door said that they had not seen him all week. A few days later, I came to look for Matthew again, and found him slumped in a chair, asleep. I startled him when I walked in, and he apologized for not showing up for our appointment. He was sorry, but there were problems at home. A girl had been raped, his niece. I had met her, she was the tall, shy one who had kneeled down when she brought me a cup of tea. She was all right, he said, bleeding a little. His wife, who was also a healer, had treated her with some traditional herbs. It happened at night, and Matthew knew who had done it, a man of about twenty who lived nearby.

  In order to press charges, Matthew needed a document that had been signed by the local police commander requesting that the girl be examined by the police surgeon. Matthew had taken the girl to the police station, but
when they got there, they had been asked to wait. He and the girl waited all afternoon. They were eventually told that the commander would not have time to see them that day.

  The next day, Matthew went to the police station with the local government official. The police chief now had time to see them. He said, “Gentlemen, we have a problem in Uganda.” The government had not paid the police surgeon, so what could they do? The police surgeon could not work without money. The form for the report would cost 50,000 shillings. Matthew refused to pay. He said he would call a lawyer. Rape was a serious crime.

  I asked Matthew if he needed any help. I knew about a group of tough women lawyers in town who might take the case. No, Matthew said. He knew what to do.

  The following week, I came to see Matthew again, and this time he was in better spirits. The situation has changed, he said. The mother of the boy came and prayed to us. She was worried. You know, the penalty for rape in this country is death.9 The police would shoot her son if they caught him. His niece was OK. She had gone back to her father’s village, about fifty miles away. She was not hurt so badly. He thought the hymen was already broken.

  I wondered, but didn’t ask, how much Matthew had been paid by the rapist’s family. Fifty dollars? A hundred? Matthew was following traditional Ugandan law, according to which a woman is the property of her family. A woman’s rights belong to her male relatives, so in cases of rape a woman cannot be wronged, but they can demand compensation. In many African countries, the crime of rape has only recently begun to be taken seriously. Now, because of the AIDS epidemic, rape and other forms of sexual coercion and abuse are drawing increasing attention from lawyers, researchers, and women’s groups. The findings are alarming.

  According to the UN, around 40 percent of Ugandan women have experienced some form of sexual violence in their lives, and the situation is probably similar throughout East Africa, and worse in Southern Africa. This includes rape and coercion by husbands and boyfriends, as well as strangers. There are indications that sexual violence contributes enormously to the HIV epidemic. Recent studies from Tanzania and Uganda have found that young women who are HIV-positive, whether married or not, are seven to ten times more likely to have been beaten up or raped or otherwise coerced into sex in the past year, compared to women who are HIV-negative.10 For epidemiologists, an increased risk of seven-to tenfold is very significant, like an archaeologist’s “key find,” the artifact that just might explain everything else.

  Poor women in Africa often have very little control over their reproductive lives. How many children they have, and when to have them, and whether to have sex with a condom: these are decisions in which many poor African women have very little say. The long continuum between actual rape and the kind of persistent intimidation that makes women afraid to raise the issue of condoms with husbands they know are philandering contributes to a general climate of powerlessness. Police corruption and the weakness and poverty of justice systems (both exacerbated by World Bank–mandated cuts in public sector salaries and spending) only reinforce a prevailing disregard for women’s rights and feelings.

  It is not known why violence against women is more common in some societies than in others. In World Mental Health,11 the anthropologist Robert Desjarlais and colleagues speculate that recent civil conflicts in developing countries may have more long-lasting effects on social life than the European wars of the early twentieth century did, because the nature of war has changed. The object of so many recent conflicts has been the control of populations, rather than territory, so civilians are not just bystanders but often targets of violence. During the two World Wars, the majority of casualties were soldiers, but during the wars of the past forty years, most casualties have been civilians, some of whom have died in particularly grotesque ways. When combatants cut off the heads of their victims and place them on stakes, or rape all the women in a village, the aim is not just to kill the enemy but to demoralize him. Such conflicts may particularly fuel men’s rage by challenging their self-respect. At the same time, such conflicts destroy the very social ties that normally help prevent abuse of women.

  It is difficult to make connections between larger social conditions and the personal behavior of individual men and women. But it is striking that in so many places where political violence has ended, apparently random acts of violent crime, particularly against women, continue and even increase. Writers have described how in Cambodia, Mozambique, Uganda, and El Salvador rape, domestic abuse, and intimidation of women are a feature not only of war itself, but of its aftermath as well.12 In South Africa, while the political violence has died down, rape and other forms of violence have become a part of everyday life. An adolescent girl from Gauteng province recently told an interviewer, “They find you on the street and they force you to go home with them so that they can have sex with you. It is rape, but we don’t call it rape because they are our boyfriends.”13

  The authors of World Mental Health ask, “To what extent does domestic and street violence result from prolonged repression and conflict?” At the moment, they conclude, we don’t know, nor do we know to what extent abuse of women is related to what the authors call “structural violence,” which includes poverty, migrancy, inferior education, and other extreme forms of disadvantage.14

  The causes of the African AIDS epidemic are complex, and sexual violence is not the entire explanation. Certainly not all African men abuse women. Far from it. Nor are all cases of HIV infection in the region to date likely to be the result of forced sex. But abuse of women by poor, frustrated, angry men has been a factor in making HIV as widespread as it is. Once HIV begins to spread in the general, heterosexual population, all such relationships become much riskier. In other words, violence against women might have been the spark that set off the blaze. Furthermore, as more people learn about how to protect themselves from HIV, those who remain most vulnerable to infection will likely be those who suffer most from injustice, anger, and abuse. For these reasons, the results of prevention programs may continue to be disappointing, unless the rights of women are strengthened at the same time, and unless sub-Saharan African countries can provide young men with an alternative to poverty and hopelessness.

  3.

  What is the future of AIDS in Uganda? The answer may well depend on whether the country remains at peace. But all was not well when I returned there in April. Since 1996, Uganda’s army has been fighting various factions in the Congo war, first the Hutus who fled from Rwanda after the genocide in 1994, and then the government of Laurent Kabila and his supporters from Zimbabwe, Namibia, and Angola, and now the army of Rwanda, which, confusingly, was until recently Uganda’s ally. The war has been a drain on Uganda’s economy, and has increased tensions among the nation’s many ethnic groups. In April, the UN released a report accusing high-level Ugandan army officers, including Museveni’s brother, Salim Saleh, of systematically looting gold, diamonds, timber, coffee, livestock, elephant tusks, automobiles, and private property, exporting them from the Congo to Uganda, and then reselling them through his own companies to buyers all over the world who have chosen not to ask questions about where the goods come from. Some of these goods were allegedly stolen, and some allegedly bought with counterfeit Congolese francs and US dollars.15

  Salim Saleh has also been involved in several dubious privatization deals, in which state-owned companies and banks were sold off for far less than they were worth to companies he owns. In one disturbing account,16 businessmen who attempted to buy a government-owned hotel said they were threatened with death because they refused to pay a bribe to Museveni’s brother. Smuggling and extortion are hardly unknown in Africa, but in Uganda it is creating a tiny, corrupt wealthy class with very close ties to the President, and this seems all too familiar to those who recall the country’s terrible past.

  In March 2001, Uganda held presidential elections. There were six candidates, one of whom, a medical doctor and retired colonel from Museveni’s National Resistance Army, was a seri
ous challenger to Museveni. Kizza Besigye fought alongside Museveni during the war in the 1980s, and later joined his government. He decided to run against Museveni because he believed the President had been in power for too long, and had become complacent and corrupt. Besigye has been critical of Uganda’s involvement in the Congo, and of increasing human rights abuses within Uganda itself. He also supports multiparty democracy, while Museveni believes the country should remain in the hands of his own National Resistance Movement. During the months leading up to the election, there were numerous episodes of violence, kidnapping, and torture.17 By far, most offenses, according to newspaper reports, and according to Human Rights Watch,18 were carried out by Museveni supporters, including Museveni’s personal guards, the Presidential Protection Unit, against Besigye supporters. Besigye challenged the election results in court, alleging that two and a half million ghost votes had been cast in Museveni’s favor. The Supreme Court decided, by a vote of 3–2, not to annul the elections, and Museveni was recently sworn in to another presidential term.

  It is widely believed, however, that the Court had originally decided that the elections had not been legitimate, but that the evening before the ruling, Museveni threatened the judges that he would call in the army if they did not revise their decision.19 Besigye has decided not to challenge the election results again, and, despite the fact that the election was clearly flawed, this is good news for Uganda. If he did, the pre-election violence might well escalate into yet another civil war. In that case, it seems clear, no HIV prevention program could prevent another surge in infection rates.