A major epidemic of AIDS is sweeping through the most populous regions of southern Uganda, and researchers here say they believe that 10% of the sexually active population in the area--women as well as men--may be infected with the deadly virus.
Physicians studying the disease at Kampala’s Mulago Hospital describe the situation as “a disaster” and compare it to a nuclear accident.
“It is as if an entire segment of the population here had been irradiated,” Dr. J. Wilson Carswell, one of the researchers, said recently. “What we’ve got here is a sort of Chernobyl.”
When Carswell, a Scottish physician at Mulago who has been in the country for 18 years, was asked if Uganda was experiencing an AIDS epidemic, he replied: “It was an epidemic last year. It is now a disaster. It is going to wipe out many, many people here.”
Uganda, an East African nation with a population of 14 million, has just ended a five-year civil war which some observers believe may have taken as many as 200,000 lives. The country is still scarred by the bloody rule of dictator Idi Amin, under whose reign another quarter of a million Ugandans may have been killed. Now, on top of those tragedies, doctors here say they fear the new disease, which destroys a vital part of the body’s immune system, could kill several hundred thousand Ugandans over the next 10 years.
In a report recently submitted to the Ugandan Ministry of Health, the Mulago researchers say they believe the number of AIDS patients admitted to hospitals will continue to rise.
“There is no evidence from Uganda or elsewhere that the disease is likely to decline in the near future,” their report concluded. “On the contrary, all the facts suggest that the number of affected patients will continue to increase, and the epidemic to spread at the present rate.”
One reason that the doctors fear that the disease is spreading rapidly is that AIDS in Uganda, as in other areas of Africa, appears to be transmitted mostly by heterosexual sex. In the United States and Europe, homosexuals and intravenous drug users are those most at risk--a much smaller portion of the population.
The researchers say that AIDS-acquired immune deficiency syndrome--has now become the leading cause of death in Mulago Hospital, the country’s largest medical facility, and that AIDS admissions have risen steadily over the last months and now stand at three a day.
By the end of 1985, they say, 170 AIDS cases had been documented in Uganda. In the first four months of this year, 285 more cases have been documented at Mulago alone.
The physicians say that their research indicates that the rate of infection among young adults in the populous southern regions of Uganda may stand at 10% or higher.
Several Thousand Infected
“We may be getting on toward several hundred thousand infected,” said Carswell. “The indications are that 10% of the healthy young adults may be infected with the AIDS virus, and if that isn’t a disaster, I don’t know what is. It’s like these people are carrying a time bomb inside their bodies--it just has a long fuse.”
The doctors reach their estimate of 10% by extrapolating from a variety of studies and such factors as hospital admissions and death rates. They cite, for instance:
--AIDS cases now account for more than 10% of the admissions to the hospital’s medical wards.
--A study of 900 women at a prenatal clinic in Kampala found that 14% of those tested had HTLV-III antibodies. HTLV-III is the virus responsible for AIDS.
--A study of 300 blood donors which discovered that 11% had the AIDS antibodies.
--A study done in late 1985 that found HTLV-III antibodies present in 10.7% of a sample of 103 pregnant women in the Kampala area.
--Another sample, in which the virus was found in seven out of 70 2-year-old children suffering from measles.
--Yet another study of 270 healthy adults, conducted in the vicinity of the hospital late in 1985, which turned up 11.8% positive. By comparison, tests on blood donors in the United States find the AIDS antibodies in 0.1% to 0.25%.
More Research Needed
The doctors in Uganda concede that their test samples are still small and that more research is urgently needed. But they say they believe that the results gathered so far, despite their narrow base, are a matter of grave concern.
“What our numbers suggest,” said Dr. Rick Goodgame, an American missionary physician on the staff at Mulago, “is that we have more people with the virus in Uganda than in the whole of the United States. Numbers like this have not been seen anywhere in the Western world.”
They have, however, been mentioned in a number of Western medical journals in articles about the incidence of AIDS in African countries. The 10% figure has been cited for blood studies done in Rwanda, Zambia and Uganda.
In their report to the Health Ministry, the doctors at Mulago emphasized that the number of documented cases seen “must represent only a small fraction of the total number of cases in Uganda, where medical recording is currently very poor and where many patients will not come to hospital for a disease they regard as hopelessly fatal.”
Another obstacle to getting a more accurate picture of the disease’s infiltration has been the civil war. The southwestern area of the country, where the outbreak of the disease was first reported, was cut off by the fighting until February.
The victory in January of the National Resistance Army, whose leader, Yoweri Mouseveni, is now president, seems to have returned peace to the countryside. But the nation’s institutions have been damaged by years of physical and economic neglect.
Mulago Hospital, which is associated with the Medical School at Makarere University, has a long tradition of service and research, but it has suffered along with the rest of the country. It is plagued by interruptions in its water supply. Electricity goes off for hours, or days, at a time. Doctors say the hospital is frequently without soap or disinfectant. Sterilizing equipment has broken down. There are no rubber gloves.
Most crucially for those fighting the AIDS epidemic, Mulago now has no equipment to screen blood used for transfusions, and the doctors fear that the disease is being spread by contaminated blood as well as sexual relations. Mulago uses about 20 units of blood daily.
“If you get a transfusion here there is an 11% chance that you are getting the virus,” said Dr. Nelson Sewankambo, a Ugandan physician.
Medical facilities at Mulago, as in all of Uganda, have become severely depleted in the political and economic strife that has dominated the country for most of the last 18 years.
One mission hospital in Kampala has been given the blood-screening equipment necessary to carry out the standard test, known as ELISA, to detect the HTLV-III antibodies, but it only arrived in Kampala last Tuesday and is not yet in operation. The British government has promised to buy one of the screening devices for Mulago, and the European Economic Community has pledged two others for the country, but no one is sure when they will arrive.
In the meantime, blood and tissue samples have been sent for analysis to England, where a London virologist, Dr. Robert Downing, has done most of it free of charge.
In their report, the doctors stressed that AIDS in Uganda appears to be a venereal disease transmitted heterosexually.
“The disease affects adults, mostly aged between 18 and 45 years,” the report says. "(Both) sexes are more or less equally affected. Patients with the disease come from all sorts of social backgrounds, and from all parts of Uganda. Cases have not been seen in children of primary school age, nor in the very old.
Risk Factors Vary
“The risk factors in acquiring the disease in Uganda are thought to be heterosexual activity, receiving infected blood transfusions and being born to an infected mother. Homosexuality and intravenous drug abuse, both of which are very uncommon in Uganda, are not thought to have been implicated in any case in this country.”
In a series of interviews, Carswell, Sewankambo and Goodgame point to promiscuity among heterosexuals as a factor in the disease. Their studies indicate that those who have contracted AIDS may have been especially active sexually.
The doctors have urged the Ugandan government to launch an urgent public education campaign designed to explain that “transmission of the disease will only be broken by the establishment of stable mutually monogamous sexual relationships.” They add that if that advice is not acceptable, the use of protective devices, such as condoms, should be recommended.
They also requested that the government provide protective equipment and materials to help relieve the concern among health workers, some of whom shun AIDS patients out of fear of contracting the disease.
A Disease Called ‘Slim’
The disease first came to the attention of medical authorities in Uganda in 1982 in the southwestern district of Rakai, where it became known as “slim,” a tag derived from the severe weight loss that afflicts its victims.
“Slim,” the doctors say, turned out to be enteropathic, or intestinal, AIDS, which often started with a skin rash. Fevers, persistent diarrhea, sores in the mouth and a fungal infection of the mucous membranes of the mouth and throat followed. The condition was invariably fatal, usually within a year of the onset of the first symptoms. A virulent form of Kaposi’s sarcoma, a skin cancer, was also commonly associated with the disease.
Sewankambo says that now evidence is beginning to indicate that tuberculosis may be one of the opportunistic infections plaguing AIDS victims. In a study he is preparing, at least 19 of a group of 27 tuberculosis cases have turned up positive for the HTLV-III virus. The Ugandan team says it has evidence that the disease is beginning to manifest itself in the neurological processes--the nerves and the brain--with post-mortem examinations showing signs of encephalitis, meningitis and what one examiner described as “focal brain rot of unknown origins.”
Disease Strikes Brain
“In other words,” Carswell said, “this disease is not only attacking the white blood cells, it’s striking at the brain. This is consistent with the course of research in the United States and Europe.”
Early tests for AIDS in Africa turned up a large number of false positives for the HTLV-III virus, but the doctors at Mulago, whose laboratory tests in London have been carried out on the ELISA testing system and confirmed by an even more reliable test known as the Western Blot, say they do not believe they are getting false positives.
“We are able to get the virus itself from the serum,” one of the doctors said.
Scientists have not yet determined how long it takes for a person who shows positive for the HTLV-III antibodies to become ill. But, Carswell said, it is the growing belief of researchers that healthy persons who are found to have the antibodies eventually do ge1948284008studies vary on the percentage of those tested positive for antibodies who eventually succumb to the disease, ranging from 10% to 40%.
The doctors say their reports and requests have been received encouragingly by the minister of health in the new government, Dr. Ruhakana Rugunda, who has urged them to speak to the local press to launch an educational campaign. So far, however, no organized campaign has begun, and officials in the Ministry of Health were reluctant to speak about it last week while the minister was out of the country.
The physicians are hoping that Rugunda’s apparent openness on the issue will set the tone for the government in dealing with the AIDS issue, which has been dealt with most reluctantly by most African governments.
“What we have here is a natural disaster,” Sewankambo said. “It is nothing to be ashamed of. The more people who know about this, the more lives we will save.”