AIDS: A GLOBAL ASSESSMENT : AFRICA : Toll Threatens Hard-Earned Gains in Nations With Meager Resources

Margaret Nandawula’s father, a once-prosperous trader, sold the family home last year to pay a few doctors and, when they did not help, a few witch doctors, who could not help either.

Then he was buried amid the banana trees behind her grandparents’ house here, gone before 35. This year, Margaret’s mother was buried next to him.

Margaret, 13, and her five brothers and sisters were orphaned by the disease that people here call “slim”--acquired immune deficiency syndrome.

The AIDS epidemic in this region of southern Uganda is among the gravest in the world. While dozens of AIDS orphans peddle ground nuts on the streets, adults go to funeral after funeral. Seven AIDS victims were buried in one recent work week in Kyotera, population 30,000.

“A lot of people, they are dying,” Margaret said not long ago, sitting cross-legged on the dirt floor of the grandparents’ house, her 9-month-old sister on her lap.

Her mother called the infant Birabwa--”what will come is God’s will.” Birabwa, born after her parents had developed the disease, has a 50-50 chance of dying of AIDS before she is old enough for first grade.

Orphans and infants are a major, frightening part of Africa’s AIDS epidemic. The disease here spreads primarily by heterosexual contact, and roughly equal numbers of men and women--often mothers and fathers--are affected.

Large numbers of women with AIDS, in countries with the world’s highest birthrates, mean thousands of newborn children in jeopardy. A recent study predicted that 6,000 infants will die of AIDS this year in Zambia alone; fewer than 400 babies have died of AIDS in the United States since the disease was identified.

The AIDS epidemic in some urban pockets of Africa appears to be more severe than anywhere else in the world. But recent evidence indicates rural areas have much lower rates, and large sections of the continent, including most of West Africa, appear to have fewer cases of AIDS than the United States or Europe.

No one knows how many people will die of AIDS in Africa in the coming decade. Most of the deaths are expected to be concentrated in a thick band of south-central Africa stretching the width of the continent from western Zaire to eastern Tanzania.

In half a dozen capitals in that region, including Kinshasha, Kampala, Lusaka and Kigali, as much as a fifth of the sexually active population, both men and women, is carrying the virus that causes AIDS, according to recent studies. That level of infection substantially surpasses New York and San Francisco, the hardest-hit cities in the United States.

“Most Americans can still, with a fair degree of justification, comfort themselves with the argument that AIDS isn’t going to hit them,” said Jon Tinker, president of the London-based Panos Institute, which studies Third World problems. “That isn’t the case in Africa. Every sexually active adult is vulnerable.”

Thus far, however, AIDS has infected large numbers of Africa’s urban professionals, in whom developing countries have invested much of their meager resources for education and training. A massive death toll among those future government and business leaders, some African experts argue, could threaten the political and economic well-being of several nations.

In this region of southern Uganda, for example, a doctor and a high-level government official have died in recent months. A small U.S. embassy in one Central Africa capital has lost several African employees to AIDS.

When AIDS first appeared in Kyotera seven years ago, it struck the wealthiest men in town--those who thrived in this region by sailing the glassy waters of Lake Victoria to trade everything from paraffin to radios in nearby Tanzania.

Suddenly they were wasting away in alarming numbers, and no doctor seemed capable of stopping it.

Villagers figured the trouble was not medical so much as spiritual. Perhaps, people said, the traders had the bad sense to leave unpaid bills with the bewitching tribes on islands in the lake. It had to be a curse.

But then the traders’ wives began dying.

Badru Rashid, chairman of the Revolutionary Committee, or town council, remembers seeing one of his friends begin to lose weight in 1980.

“I told him he was slimming up like those new slim-cut shirts,” Rashid recalled. A few months later the friend was dead. By then, everyone was calling it “slim disease.”

Health officials think the traders probably picked up the disease from some of the thousands of prostitutes who cater to the truckers and businessmen traveling long distances on the roads of Africa, away for weeks at a time.

AIDS has killed about 3,000 of the 300,000 residents of this district, and they now die at the rate of one a day, officials estimate.

No one knows for sure the extent of AIDS here, however. Health records are poorly kept, if they are kept at all. Even if the town had facilities to test for AIDS, which it does not, few could afford the $20 fee and fewer would want to know the results.

“In Europe, you have a machine, and you make a record,” said Dr. Fred Muzito, who runs a private clinic in Kyotera. “But here it is a matter of guessing work.”

Studies of blood donors and other groups paint a varying picture of how widespread the epidemic has become in some parts of Africa.

Among the worst-hit cities is Kigali, Rwanda, where 18% of the sexually active residents are thought to carry the HIV virus, which causes AIDS. The rate is about 15% in Zambia’s capital, Lusaka, and Uganda’s capital, Kampala.

No cases have been reported to the World Health Organization in Zaire, yet studies in Kinshasa have shown an 8% infection rate among adults; in Brazzaville, Congo, it is 5%, and in Bangui, Central African Republic, it is 4%.

Infection rates among prostitutes and people treated for sexually transmitted diseases are even higher, ranging up to 66% in several Central Africa cities.

A study of a small group of prostitutes in Nairobi who cater mostly to cross-continent truckers, averaging 1,000 partners a year, found none with the HIV virus in 1980 and 53% carrying the virus in 1983. Some believe that has soared to 80% now.

In West Africa, however, viruses closely related to HIV have been found to be fairly common, with 10% to 15% of the populations infected. But few AIDS-like illnesses have been found there.

Contributing to the spread of AIDS in the cities is the perennially high rate of sexually transmitted diseases and the problems associated with rapid urban migration.

Scientists are heartened by early indications that the disease may not be as prevalent in rural areas. Outside of Kampala and two southern districts that include Kyotera, the rate of infection in Uganda is about 1% or less, according to a recent study.

Tanzania, however, has a rural AIDS epidemic similar to that in southern Uganda, researchers say. Of barmaids tested in one rural Tanzanian village, for example, 41% were infected with the virus.

The full extent of AIDS in Africa is not known, partly because keeping track of a new disease is not high on the list of priorities for poorly equipped health care systems trying to grapple with many other diseases.

African governments have also been late in facing up to their AIDS problem. For several years, many governments denied they had any AIDS cases, suppressed scientific studies and threatened to expel foreign doctors.

Acknowledging an AIDS epidemic, African leaders seemed to believe, would endanger their tourist trade and discourage the foreign investment and Western assistance that many rely upon.

Dr. Jean-Louis Lesbordes, a French military physician at the Bangui Hospital in the Central African Republic, diagnoses about one new case of AIDS every day. His African colleagues at the hospital report about one every month.

“I go down through the beds in this hospital and see several new AIDS patients every week in the care of other doctors here,” he said. “Yet I am the only one taking blood samples. I am the only one diagnosing AIDS. So, officially, nearly all the AIDS patients in this country are in my service.”

Lesbordes has been threatened with expulsion at least once.

“Speaking of AIDS is more dangerous than AIDS for doctors in Africa,” he said. Scientific reports suggesting that AIDS originated, or at least first became a significant problem, in Africa prompted angry reactions from many African governments.

Newspapers on the continent still carry more stories, editorials and letters debating the origin of the disease than reporting the extent of AIDS or what can be done to stop its spread.

“We all say it’s a virus from the other country,” said Dr. Bernard Lala, director of the sexually transmitted diseases program for the Central African Republic. “Here we think AIDS is coming from Zaire. In Zaire, they think AIDS came from American and French paratroopers.”

In Zaire’s capital, Kinshasa, in fact, some Zairians mockingly say the French acronym for AIDS, SIDA, stands for syndrome imagined to discourage amour.

The attitude of governments here has recently begun to change, however. Blood screening has been set up at the hospitals in most major cities and is slowly being extended to the rural areas as well.

“A year ago it was difficult to even have an open discussion with governments in Africa about AIDS. Now we’re talking with them,” said Dr. Jonathan Mann, director of the World Health Organization’s special program on AIDS.

“There’s a great deal of prevention taking place compared to a year ago,” Mann added. But he said he is concerned that the most rudimentary efforts to halt AIDS spread, such as blood screening, are being implemented too slowly.

With millions of dollars from the World Health Organization and Western relief agencies, many African countries have launched public education programs designed to persuade people to change their sexual behavior: Reduce their number of partners, use condoms and avoid prostitutes.

The slogan in Uganda is “love carefully.”

Uganda, the African country that has been the most frank about its AIDS epidemic, recently received $6 million in international assistance for the first year of a five-year plan that will include an education campaign, epidemiological studies, laboratory upgrading and the acquisition of equipment needed to protect the country’s blood supply.

But Africa still has many obstacles in its battle to stop the spread of AIDS, which remains little understood.

Information campaigns do not always run smoothly on a continent with hundreds of languages, the world’s highest illiteracy rates and very little money. One can find more television sets in an American neighborhood than in most African countries.

Just a few months ago in Lagos, Nigeria, a city of highly educated and well-traveled Africans, immigration officials at the airport decided a Nigerian arriving from the United States had AIDS.

Nigeria has reported only a few cases of AIDS. Word spread quickly in the baggage claim area, and dozens of people bolted for the exits, leaping over luggage to get out of the room.

In the excitement, the suspected AIDS patient walked out. He was found a few days later and tested. He did not have AIDS. But he had been carrying an envelope in his passport with this return address: Legal Aid Society.

Pushing AIDS prevention in Africa is hampered by the massive health problems that already exist and the lack of doctors and clinics to help.

“Possibly AIDS is the least prevalent health problem in this country,” said Job Lema, the chief of the World Health Organization mission in Uganda. “So many communicable diseases have become epidemics here.”

Sleeping sickness, a usually fatal disease transmitted by flies, has tripled in Uganda since 1981, with more than 1,000 cases reported this year. A recent cholera outbreak killed dozens, and an outbreak of bubonic plague killed 27.

Those epidemics, serious as they are, can be stopped by the quick action of health officials and usually take precedence, Lema said.

“With AIDS, you have to change people’s behavior and make them realize they’re in danger,” Lema said. “That’s difficult, especially with an illiteracy rate of 50%. You can’t ask them to stop having sex. That’s a human act that very few people will stop doing.”

Although shipments of condoms from the United States to Africa have increased sharply in recent months, it is not clear whether they are being used.

The U.S. Agency for International Development, citing a large demand for condoms in Kenya, has increased its monthly distribution from 100,000 to 400,000. Extra shipments of condoms were flown in recently, and the American agency has placed an order for 5 million condoms for the rest of the year in Kenya.

But in Uganda, where condoms are called “American socks,” health officials doubt they are widely used. One of the problems is that most condoms distributed in Africa do not carry written instructions on usage because some governments consider condoms obscene to begin with.

“We get tons and tons of condoms from the Americans,” Lema said. “But I doubt people know how to use them.”

The tremendous shortcomings of the health system in a country such as Uganda also are difficult to change overnight.

Sterilization of needles at the rural and urban hospitals of Uganda has broken down, according to Lema. Injections are a favored method of treatment for many illnesses, and unsterilized needles are considered a method of transmitting the AIDs virus.

In the Central African Republic, a survey of AIDS patients indicated they had, on average, four injections in the preceding year for illnesses such as malaria. At least one of those four injections, according to the study, was probably not sterile.

“We try to give people pills, but people don’t consider it medicine,” said Lesbordes at the Bangui Hospital. “The feeling is that an injection, something that hurts, is doing some good. And African doctors give many injections.”

Scientists are still unsure how the AIDS virus is passed from mothers to unborn children and infants. But they estimate that about half the babies born to carriers of the virus will contract AIDS and die before their fifth birthdays.

In Rwanda, 20% of the AIDS victims are children. An urban prenatal clinic in one African country found 24% of the mothers testing positive for the HIV virus. Nearly a fourth of the malnourished young children brought to one pediatric clinic in Bangui, Central African Republic, were found to be AIDS carriers.

Taking care of children with AIDS and the orphans of AIDS victims has begun to strain the traditional system of family support in African society.

In Kyotera, orphans usually end up in the homes of relatives or neighbors. Margaret Nandawula and her brothers and sisters sleep under their grandparents’ small roof with 12 young cousins.

When Kyotera Town Council Chairman Rashid’s 36-year-old brother died of AIDS last year, leaving six children fatherless, the surviving brothers began supporting the children, buying clothes and paying school fees. That is the unshirkable responsibility of tradition in many tribes of Africa.

Then, in June, another of Rashid’s brothers died of AIDS, at age 38, leaving four more children, all under 7 years old.

The burden of sending those children through school rests on Rashid and his only brother, who have children of their own.

His brother’s widow, 26-year-old Hadija Nalubega, feels doomed.

“We know that any widow can die,” Nalubega said, stroking the head of Nakatto, one of her 18-month-old twin girls.

Widows of AIDS victims here are usually isolated from the rest of the community and do not remarry. But immediately after the funeral, according to the custom here, a brother of the dead man must sleep with the widow to keep the ghost from haunting the household.

Rashid’s family weighed the risk of AIDS infection against tradition, and one brother carried out the family obligation.

In Kyotera, as elsewhere in Africa, the search for a cure leads victims to witch doctors, especially when Western medicine offers no cure.

A few wealthy AIDS victims here have paid upwards of $400 to witch doctors, most of it for small animals that are sacrificed and left at intersections. Witch doctors say the disease can be transferred to a passer-by that way.

Dumba, one witch doctor in the thick jungle outside Kyotera, sees two or three cases of AIDS a week, charging the equivalent of $5 for a first visit, his assistant said. Even when his patients die, others come for treatment.

“People die in hospitals, too,” a neighbor explained.

While many AIDS sufferers would rather not know they have AIDS, other people who become ill in Kyotera immediately assume they have AIDS.

“I think our second-biggest health problem may be the person who gets another disease, thinks it is AIDS and hopeless, and then dies because he didn’t seek treatment,” said Yorokamu Kamacerere, the district administrator.

AIDS has begun to destroy the social and economic fabric of Kyotera and altered the way its people think about the future. The town flourished for years on the area’s major north-south trucking route, near the continent’s largest lake and gateway to Tanzania’s vast and isolated rural west.

But today people are moving away; many of those who stay have given up hope.

“You can get rich and build a house and die two months later,” Rashid said. “People feel no desire to work hard.” By striking down the most productive members of societies as well as the children, AIDS promises to to severely hamper some parts of Africa, perhaps resulting in a net decline in the work force in some urban areas, according to Tinker of the Panos Institute.

“We’re talking about, in a number of Central African countries, the inevitability of massive fatalities in the 20 to 40 age group in the next five or 10 years,” Tinker said. “That impact is going to be enormous and very tough for those societies to handle.”

Some worry that the continent is moving too slowly to save itself from catastrophe.

“We feel, in the long run, that we might be wiped out,” Rashid said.

But the low rates of infection in most rural areas and what appear to be lower incidences of AIDS in West Africa have prompted some doctors to speculate that many Africans may have build up immunity to the HIV virus over the years. That is still being studied.

Others point out that Africa has survived more than its share of tragedies. Wars have taken thousands of its young men. Malaria alone claims the lives of an estimated 1 million children a year.

Those scientists believe Africans will change their sexual behavior to save their lives and that Africa’s society will remain, battered but standing.

“Maybe 1 million, maybe 10 million people will die in the next 15 years here,” said a sociologist with U.S. Agency for International Development in Africa. “But society will go on. Business and government will go on. A great tragedy will be absorbed.”

UGANDA: Population: . . 15.5 million GNP per capita: . . $220 (U.S.) Literacy rate: . . 52.3% 1,052 reported AIDS cases, actual number of cases much higher. Life expectancy 53 years; 18.6% of children die before age 5. Only 44% of the population had access to local health care in 1984 and only 2% of children received full childhood immunizations. Sources: World Health Organization and United Nations statistics. AIDS IN AFRICA Algeria . . 5 Angola . . 6 Benin . . 2 Botswana . . 12 Burundi . . 128 Cameroon . . 25 Cape Verde . . 4 Central African Republic . . 202 Chad . . 1 Congo . . 250 Ethiopia . . 5 Gabon . . 1 Gambia . . 14 Ghana . . 145 Guinea-Bissau . . 2 Ivory Coast . . 118 Kenya . . 625 Lesotho . . 1 Liberia . . 1 Malawi . . 13 Mozambique . . 1 Nigeria . . 5 Reunion . . 1 Rwanda . . 705 South Africa . . 70 Swaziland . . 7 Tanzania . . 1130 Uganda . . 1138 Zaire . . * Zambia . . 250 Zimbabwe . . 57 TOTAL CASES . . 4,924 *Zaire has many AIDS cases, according to medical journal reports, but none has been officially acknowledged by the government.