Africa Facing Reality of AIDS War Amid Social Changes in Urban Life

In the vibrant cite section of town, Mpasi, a 27-year-old army lieutenant, cast his eye over the well-dressed women occupying the velour couches of the Cosmos 2000 nightclub.

“Most of the women here are ‘free,’ ” he observed approvingly. “You can just go ahead and dance with any of them.”

But of Kinshasa’s femmes libres , or free women--a term that technically denotes any sexually active unmarried woman but in practice refers to prostitutes--40% are estimated to be infected with the AIDS virus.

Throughout the cite on any night, Zairian men who have left their wives at home roam from club to club, a graphic picture of the daunting task facing Africa’s AIDS fighters.

Hallmark of Social Behavior

For no matter what technological improvements can be wrought on the standards of health care in Africa, no matter how many condoms or blood-screening kits can be shipped into the remote bush, the disease is transmitted here mostly by heterosexual contact, and by a wide margin mostly in the cities where prostitution and promiscuity is a hallmark of the social behavior of Africa’s emerging urban middle class.

“We now have available disposable needles, and that’s 5% of our cases,” says Dr. Bosenge N’galy, head of Zaire’s AIDS program. “We can screen blood donors, which is 0.5%. But all the rest means changing people’s habits, and in that we are almost blind.”

Still, officials of national AIDS control programs from more than 40 sub-Saharan countries who met here late last month are beginning to sense a glimmer of progress in Africa’s fight against AIDS, or acquired immune deficiency syndrome.

Among the most important improvements has been the shedding of sensitivity over early, and now discredited, scientific theories that the human immunodeficiency virus (HIV), which causes AIDS, was born on the continent.

Irate over what they saw as unjustified finger-pointing by the developed world, many African leaders had chosen to ignore the scale of the problem in their countries. Research and prevention programs stagnated.

‘Most Decided to Hide’

“Two years ago, most countries wouldn’t even have allowed their participants (at a conference) to talk about AIDS,” said Dr. Lazare Kaptue, head of Cameroon’s AIDS program. “No country wanted to be accused of being the origin of the epidemic, so most just decided to hide.”

Today, African countries are among the leaders in finding creative ways of reaching and educating potential victims. They have to be, for this is a region where ordinary methods of education and communicating have difficulty penetrating very far from one or two cities in each country.

In Uganda, for example, the national AIDS committee introduces its radio broadcasts with a tribal drum rhythm recognized all over the country as a traditional warning of danger. By now the drumbeat is unalterably associated with the AIDS program.

“Everybody in Uganda recognizes the ‘Okware drums,’ ” says Dr. Samuel I. Okware, the program’s chairman.

Yet, in Africa, optimism about the fight against AIDS does not cut very deep. Even as they expressed hopefulness at having found that neighboring countries are beginning to face up to the potential impact of AIDS on their societies and economies, many African officials at the Kinshasa conference expressed concern about the scale of the problem facing them in preventing transmission of the virus.

The tasks range from changing orthodox African medical practices to altering elemental sexual habits.

In Kinshasa, the use of blood transfusions to treat malaria in children was cut back sharply last year after an international research team showed that as many as 90% of the pediatric AIDS cases at Mama Yemo Hospital, Kinshasa’s main health care center, could be traced to such transfusions. Of 68 malarial children whose transfusion history was examined by the doctors, 10 of them--or 15%--appeared to have been exposed to HIV infection from affected blood.

Clearly, this represented the principal route of HIV infection for African children below the age of 5.

The findings underscored the dangers in routine use of transfusions to treat childhood malaria, which often causes severe anemia. More than half of all children diagnosed with malaria at the hospital were receiving transfusions, most of them more than one.

The researchers concluded that of 8,900 transfusions given to children at Mama Yemo during the year of their study, mid-1985 to mid-1986, 516 involved blood contaminated with the virus.

Because blood units are not routinely stored in African hospitals, transfusions require authorities to scare up compatible donors on the spot. Most transfusions are done within hours of donation, and timely screening for HIV in the donated blood is often impossible. At one hospital in Cameroon, donated blood was routinely screened for HIV only after it was used for transfusions.

A Fundamental Change

But the most disturbing element of AIDS in Africa is its close association with a fundamental change in the way of life here: a wholesale move by the population into the cities.

Several studies have demonstrated that with a few exceptions, the prevalence of AIDS in rural districts in many parts of Africa tends to be relatively low, and stable. One 1985 study undertaken in Zaire, using a cache of 1975-vintage blood samples drawn from rural patients during a viral epidemic, showed that the AIDS exposure level among the group was only 0.8%.

A follow-up survey showed the rate in the same rural district had not risen in the 10 years that followed, while the exposure rate in Kinshasa had ballooned to 8% of the city’s population.

What was disquieting about that, says Robert W. Ryder, the American head of Zaire’s U.S.-funded Project SIDA, was how it demonstrated that in Africa “the problem is much more socioeconomic than just medical.”

Throughout Africa, urban populations are burgeoning as people move from rural districts in search of jobs. In the cities, traditional habits of life, including monogamy and abstemiousness, break down. Mothers who might have been well cared for in their villages’ barter economy become part-time prostitutes to subsist in the cash economy of the cities.

“If a woman doesn’t know where she’s going to get her next meal, she can make 300 zaires (about $1.50) tonight,” remarks one Zaire health researcher.

Problem Is Compounded

Changing people’s habits is hard enough in countries with sophisticated media and educational structures. In Africa, the problem is compounded by poor education, scant media and a health structure seriously compromised by economic recession.

In fact, many countries are now turning their attention to the state of their health facilities for the first time in years because the AIDS threat has lent the effort an urgency, as well as brought in some international donations.

So far, international donors have committed $90 million to AIDS programs in sub-Saharan Africa under a program largely administered by the World Health Organization of the United Nations. AIDS control on the continent would all but collapse without it, for effective national programs cost between $2 million and $8 million in their first year, and get more expensive after that.

“The silver lining in the cloud of AIDS,” says one World Health Organization official, “is the possibility of getting these countries to strengthen the entire health system.”

Yet even the thought of depending so much on foreign funding alarms some AIDS officials in Africa. “I worry that all of our resources come from abroad,” says Zaire’s N’galy, whose program is heavily funded by the United States and Belgium. “What if five or 10 years from now they leave? All our progress will vanish.”

Meanwhile, the very epidemiological nature of AIDS works against education and prevention programs. Because symptoms of the syndrome may not appear until years after a patient is first infected with the virus, Africa’s toll will continue to mount indefinitely even if all exposure were to end today.

“People don’t see the problem as controllable, because despite all our measures the number of cases is going up,” says Okware. “This has undermined public confidence in health services, and in themselves. They want immediate results, and that’s impossible.”

Stark Choices

For these reasons, African health officials must make the starkest choices when it comes to priorities. Treatment of patients by azidothymidine--or AZT, the promising medicine that is the only federally-approved drug in the United States for treating AIDS--can cost $1,000 per patient per month.

“It doesn’t matter whether the treatment costs $1 million per patient, or $1,000, or even $10,” remarked one Malawian health official. “None of these countries can afford an AZT program.”

Instead, African authorities deploy their meager resources where they will do the most good. That may mean writing off an entire generation of people now aged 20 to 40 (in which 50% of all AIDS cases are found in Zaire) in favor of focusing prevention programs on younger people.

Some countries do not even bother to ship condoms, the most reliable preventive device, into rural districts, because the difficulties of providing an adequate supply in the bush, much less educating people in their proper use, would make effective habitual condom use a hopeless goal.

“If a man lives in a shack and he’s barefoot, the chances are his condom will be torn,” says Dr. Okware of Uganda. “It’s probably been washed over and over.”

Local sensitivities preclude instructors from demonstrating condom use in any clear way. One official told colleagues at the Kinshasa meeting that her government refused to let her take a condom out of its package during a television program. In another central African country, an instructor on a videotape used his hand as a proxy to demonstrate how to use one; after watching the tape, villagers tried to ward off HIV by wearing condoms on their hands, like mittens.

Many also report that, despite their countries’ expressed willingness to discuss their AIDS problems frankly, AIDS is still a political mine field.

“The difficulties are political because AIDS creates a stigma,” says Zaire’s N’galy. His country recognized its first AIDS case in 1983 and immediately established an extensive U.S.-financed research effort. But not until last year did Zaire report its first AIDS cases to the World Health Organization--and then only a count of 335 cases from the first half of 1987, a figure widely assumed to be low.

Statistics Given

Although Zaire has since become much more open, pressures to minimize the problem are visible everywhere. On the first day of last month’s AIDS conference, Zaire’s minister of state for public health, Dr. Kabeya N’gandu, produced statistics indicating that 6% to 8% of people in Kinshasa were infected with HIV and the rate was rising by 1% to 3% a year.

A few days later N’gandu was confronted by a Zairian journalist who demanded to know why he had chosen to “panic” the population of Kinshasa by issuing the figures.

“We didn’t intend to create panic,” the minister replied, “but to give people the information. We want to make them aware of the danger and highlight the situation. It won’t do to hide like ostriches.”