Third of four parts
RUNDU, Namibia - On a continent where the common official response to the AIDS plague is denial, Bishop Joseph Sikongo speaks with rare candor.
''Nobody has been outspoken,'' the Roman Catholic elder said in an interview here, referring to government leaders as well as his ecclesiastical brethren. ''Just now, when we see people dying, we are beginning to pay attention. But we have not been focused, and we have failed to meet our responsibility.''
Every year, AIDS kills 10 times more Africans than die in wars annually, and poses the single biggest threat to development on the continent, yet very few leaders - in parliament or the pulpit - have anything to say about it. Sub-Saharan countries spend about $160 million fighting 4 million new AIDS cases per year, and most of that is foreign aid, according to US government figures. By contrast, the United States spends $880 million on just 44,000 new cases annually.
''By any measure, the HIV-AIDS epidemic is the most terrible undeclared war in the world, with the whole of sub-Saharan Africa a killing field,'' said UNICEF executive director Carol Bellamy last month in Lusaka, Zambia, in a speech at the annual conference on AIDS in Africa.
Strikingly, no African heads of state attended the meeting, the most important periodic conference on the African AIDS epidemic. Not even Zambian President Frederick Chiluba, whose office is just minutes away.
''There is a need for political commitment at the highest level, and little explanation for why that commitment is not there,'' said John Caldwell, who attended the conference as an expert on Africa from the Australian National University in Canberra. ''AIDS must be the central issue on the African political agenda.''
A few African leaders, such as South Africa's Thabo Mbeki and Ethiopia's Negasso Gidada, have begun to move the AIDS epidemic higher on their priority lists. But most remain silent or pay the problem only lip service, leaving the international community and underfunded private organizations to confront the epidemic.
This reticence has had dire consequences. Existing AIDS-related laws are not enforced, allowing discrimination to go unchecked. Stigmas endure. Treatments remain costly and inaccessible. Rape and other sexual violence flourish. Insurance companies refuse to cover people infected by the human immunodeficiency virus, which causes AIDS, and withhold benefits to families of policyholders who have died of the disease. Half-hearted education efforts make little impact on risky behavior.
These factors ``drive the epidemic underground,'' where it continues its sweep through the population, said Mark Heywood, director of the AIDS Law Project at the University of the Witswatersrand in Johannesburg.
More than 15 years into the now-raging AIDS epidemic, as African countries strive to cope with the burden of rising death rates, official denial is hard to fathom. AIDS, it is widely suspected, has taken a personal toll at the highest levels of government. Corridors buzz in every country with stories of ranking politicians who have died or lost family members to untimely deaths. Namibian President Sam Nujoma lost two sons and a daughter-in-law. Bennie Mwiinga, Zambia's minister of local government and housing, died on the eve of the AIDS conference last month, leaving delegates to speculate about the end of a young and prominent political figure.
In each case, the official cause of death was listed as something else, though Western diplomats and some African health experts all said privately that AIDS was the culprit.
Former Zambian President Kenneth Kaunda admitted that he lost a son to the disease, and the preeminent South African judge Edwin Cameron has disclosed his positive HIV status. But Africa, sadly, still awaits its Magic Johnson, someone of mass popular appeal stepping forward with personal testimony to break the myth and stigmas of the epidemic, to say unequivocally that AIDS affects everyone.
``These leaders don't understand that they just leave people laboring to explain why they are silent,'' said Beatrice Were of Uganda's International Community of Women Living with HIV/AIDS, an advocacy group. ``They deepen the stigmas attached to AIDS.''
The silence may be rooted in fear of failure. African leaders do nothing, Caldwell argues, because they think they cannot influence the sexual behavior of their most important constituency: young and middle-aged men. They may also be bound by traditional African taboos about sex. Such issues are seldom brought into the open, let alone discussed between partners. Few couples, experts on African sexuality say, communicate about the role of sex within their own relationships.
As former South African President Nelson Mandela said last March in one of his last official comments about AIDS, ``HIV/AIDS is one of those critical issues which demand visible leadership.... Why understand why there is this silence? It is because transmission occurs primarily through sex, which is not openly discussed.''
Martin Foreman, director of the AIDS project at the Panos Institute, a London-based research center, raises another possible reason for official reticence: traditional notions about African masculinity. Men, he argues, are supposed to be emotionally and physically strong. Many cultures expect men to have multiple sexual partners. Powerful leaders see the AIDS epidemic as threatening their status, both as men and as officeholders, Foreman said.
Whatever the reason, the lack of political will has had measureable consequences. In study after study across sub-Saharan Africa, most people indicate that they have a basic knowledge of how HIV spreads, how to block transmission, and that the virus is lethal. But they also do not perceive themselves to be in danger. While an increase in knowledge about HIV and AIDS has resulted in marked changes in sexual behavior in countries like the Netherlands, Australia, and Thailand, awareness has not resulted in a decrease in high-risk behavior in the majority of sub-Saharan African countries.
``The knowledge of HIV is high, but disassociated with risk,'' said Karen Tate of the information and education department of the Ministry of Health in Rundu, one of the most affected areas in Namibia. ``So even if people say they know about HIV, there is a gap between that knowledge and behavior. Behavior is based on immediate needs,'' rather than prevention of something that poses delayed risks.
Infection rates remain stubbornly high as a result, especially among the youngest age groups of sexually active adults, those ironically, those most aware of the dangers of the virus and how to protect themselves.
Ten African countries, most represented by their health ministers, declared AIDS a national disaster during the Zambia conference last month. They committed themselves to providing more political leadership, increasing resources devoted to a national response to the epidemic, and making HIV/AIDS a priority in all developmental programs. They also vowed to introduce initiatives to address behavior and encourage discussion to create a more supportive environment for those infected and dying.
``What's coming through is that there is starting to be accountability at the highest level,'' said UNAIDS director Peter Piot in an interview. ``But denial is still a fundamental aspect of the epidemic. Some African leaders are speaking out, in some places the machinery is in motion, but that doesn't mean we have action.''
The new resolve spelled out in the declaration also begs questions about how African countries apply AIDS-related laws and policies already on their books, as well as about the budgetary decisions they make. In 1997, the countries of the Southern African Development Community, a trade bloc, adopted a code for HIV/AIDS and employment, agreeing to incorporate its provisions in national legislation.
Requiring important education programs and protection of workers' rights, ``the code will aim the code aims ``to ensure non-discrimination between individuals with HIV infection and those without, and between HIV/AIDS and other comparable health/medical conditions.''
But national priorities have not reflected adherence to the best intentions of the code. South Africa has one of the world's most liberal constitutions, but its military is one of the leading discriminators against people with HIV/AIDS. People must submit to mandatory HIV screening and test negative prior to being allowed into the service.
AIDS activists believe one of the best ways to lessen the stigma attached to HIV is to assure confidentiality. Yet several countries have engaged in new debate this year on whether disclosure promotes the common good. Politicians argue that notification meets a society's need to monitor the epidemic. Speaking after a regional meeting of health ministers in April, Namibian Health Minister Libertina Amathila said ``the situation as it is now protects only the sufferers but not the community. The special confidentiality accorded afflicted people encourages them to infect others at random without being detected.''
Many AIDS experts denounce such arguments, saying that confidentiality is essential to encouraging people to learn their status and inform their partners. Notification to interested parties such as employers, they say, is a fundamental violation of the right to privacy and only promotes discrimination. In South Africa, a government proposal would require any health care worker who diagnoses a person as HIV-positive to file a report containing the patient's age, sex, race, medical condition, and ``probable source and place of infection.'' It also would force the health officer to inform family members and others giving care to the patient. The initiative is pending.
``Eliminating stigma must be central in the response to AIDS,'' Piot said at the Zambia conference. ``We know that three things contribute most to people learning and acting responsibly on their status, and thus protecting their community. First, access to confidential counseling and testing. Second, understanding of the incentives to do so. And third, the level of support in the environment in which they live.''
Another area of discrimination involves insurance. Underwriting companies, bracing against the rising costs of AIDS, often refuse to cover HIV - positive people or pay benefits to policyholders who die of AIDS. Across sub-Saharan Africa, doctors often omit AIDS as a cause of death, indicating on death certificates some other related illness to help families recover insurance benefits.
For countries that have begun to implement more serious national responses to the epidemic, Uganda is the model. One of the first to face a full-blown crisis, the east - African state has been hailed as a success story. President Yoweri Museveni was outspoken about HIV long before any of his counterparts, and mobilized his government to treat AIDS as a concern for all ministries and sectors. The country encourages people to have confidential HIV tests prior to marriage and promotes community-based care for those ailing from advancing AIDS.
After reaching a peak in the early 1990s, when as many as 36.6 percent of urban pregnant women tested positive for HIV, Uganda has apparently reversed infection rates. By the end of 1997, only 14.8 percent of women attending urban clinics had HIV.
Few argue with the importance of making AIDS a priority in every government department, as well as teaming up with the private and volunteer sectors. Namibia and South Africa have begun to adopt that approach.
In March, Namibian President Nujoma launched a national campaign against HIV/AIDS that called for a coordinated strategy at the national, regional, and local levels. The plan spells out goals for improved health care, education, and anti-discrimination measures. But the government has allocated only $3.5 million to implement it over five years, and interviews around the country with officials people responsible for putting the plan to work reveal an ignorance about what specifically the various programs are supposed to accomplish once they have been established.
Of all the countries in sub-Saharan Africa, South Africa faces the fastest-growing AIDS crisis: 1,600 people contract HIV every day, and within five years more than six million South Africans will have the virus out of a population of 40 million.
But the country is also the best equipped to respond to the disease. South Africa has the strongest economy in Africa and the most sophisticated infrastructure. Still, its response has been slow. Warnings of an impending catastrophy early in the decade, when there was still time to avert the worst, went unheeded amid intense negotiations to end apartheid and the opening years of majority rule. It wasn't until the closing months of Mandela's presidency when, last October, then-Deputy President Mbeki outlined a national response.
Even then, South Africa allocated only about $13 million to AIDS-related education and care programs over five years. By contrast, the government is spending roughly $6.5 billion on new military hardware, including three German submarines for a navy that faces no threat.
Mbeki, now president, shows signs of understanding the threat AIDS poses to his goals of improving the lives of the impoverished black majority. But government is still more focused on the medical aspects of HIV/AIDS, rather than on behavior and care and assistance for people with HIV and their families. South Africa, for example, will spend more than $10 million over the next three years on vaccine research for the subtype of the HIV virus most prevalent in the region.
Government officials, critics say, also show a surprising lack of knowledge about the epidemic. The new health minister, Manto Tshabalala-Msimang, won accolades for traveling to Uganda shortly after assuming office in June to learn from that country's experience. But her major initiative so far has been to rally religious leaders to help build awareness from the pulpit, despite the numerous studies indicating that ignorance is no longer a critical problem. Tshabalala-Msimang did not respond to requests for an interview.
In August the education ministry published new rules pertaining to HIV in schools. The policy outlines in detail how to administer first aid to superficial wounds, despite acknowledging that HIV is rarely transmitted through casual contact with open cuts. Conspicuously absent are specific guidelines for sex education in the classroom and punitive measures for teachers caught having sex with students.
Asked to explain these omissions last week, Education Minister Kader Asmal said ``these are matters for further discussion.'' He added: ``Teachers are embarrassed to give the facts, but the taboos must give way.''
The country is only just now beginning to deal seriously with violence against women, one of the most menacing causes for the spread of HIV. Despite new legislation broadening the definition of rape - a woman is raped every 26 seconds in South Africa - and imposing new minimum sentencing requirements, courts still show surprisingly callous attitudes.
In August, a high court judge in Bloemfontein sentenced a 23-year-old man previously convicted of a sex-offense to just 10 years in prison for abducting and repeatedly raping two 15-year-old girls. In his ruling, Judge Dirk Kotze argued that the attacks were simply the result of the man's virility, and that the victims were not virgins at the time they were raped.
For their part, religious leaders throughout sub-Saharan Africa have been mostly silent about the epidemic, despite the obvious role they could play in addressing behavior, counseling, and caring for orphans. Bishop Sikongo in Rundu says part of the reason is condoms. The Roman Catholic Church, for example, won't advocate condoms because they interfere with conception, and because such a stance might appear to be condoning types of sexual behavior that do not conform with church doctrine. Not knowing how else to respond, Sikongo said, his brethren have done nothing.
``Condoms are the easy way out,'' he said. ``They don't require sexual responsibility. We would like to see the human take charge of himself. But we have not promoted our view vigorously.''
The Rev. Barry Hughes-Gibbs, an Anglican priest near Pretoria, has been providing care for HIV-infected adults, children, and their families since 1994. The people he helps live in abject poverty, and the premise of his project is to help them move from dependence to a degree of self-suffficiency. In addition to feeding and treating patients, he also employs them in the program.
Hughes-Gibbs' program relies on foreign donors and receives no help from the government. Earlier this year, without explanation, Gauteng Province stopped sending subsidies - about $50 per adult and $150 per child. Nor does his own organization support him. Hughes-Gibbs half-jokingly says the project, which currently cares for 2,500 children and more than 4,000 adults, is successful because it isn't tied to the church.
In the absence of commitment from political and religious leaders, nongovernmental organizations are left to do the heavy work of testing, counseling, and caring for those with HIV and AIDS. And communities have begun finding innovative ways to address the epidemic at ther their level.
Some Zulu villages hold ceremonies to test boys and girls for virginity. If they pass they are given certificates and special status. Others act out the dangers and consequences of AIDS through traditional dances.
``People are not putting enough pressure on African governments,'' Caldwell said at last month's conference in Zambia. ``African governments are not putting enough pressure on Western governments and international systems. The conspiracy of silence must be broken.''
Tomorrow: US black leaders react
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This story ran on page A01 of the Boston Globe on 10/12/99.
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Part 1
