Plagues in World History (33 page)

Another way in which Africa differs from the rest of the world in its experience with AIDS is the sheer variety of circumstances and contexts in which the disease has historically evolved and currently exists in its status quo on the continent. In western equatorial Africa, where the disease most likely began, the epidemic matured early and has for the moment stabilized at seroprevalence rates of around 6 percent or less. Factors that have facilitated AIDS’ spread there are thought to include widespread poverty, prevalent tropical diseases, wide sexual networks in some urban areas, such as Kinshasa, and the popular use of blood transfusions and syringe injections; on the other hand, the almost universal practice of circumcision (thought to limit the spread of STDs), as well as the difficulty of travel in the region and transport disruptions caused by war, are likely to have helped curb the scope of the epidemic.40 In east Africa, where the disease migrated next, HIV prevalence rates are likewise currently stable at 6 percent or less, which represents a dramatic decline from highs in the teens and twenties in some countries, such as Uganda, during the 1990s. Transmission factors in this region include transient populations—such as truck drivers and migrant laborers—who traveled along the trans-Africa highway, an associated service economy of commercial sex workers, soldiers and refugees dispersed by civil wars, networks linking urban and rural areas, and a patriarchal and prudish culture (especially toward condoms and circumcision) in Christian communities. Uganda under President Yoweri Museveni is often held up as an example of the beneficial results of an enlightened AIDS policy, where as early as 1981 the government embarked on an open and frank discussion of the epidemic and took a “multi-sectoral” approach to changing high-risk behaviors, such as by advocating “zero grazing,” or monogamy, on billboard signs. This was not entirely smooth sailing, as Museveni for a time opposed condom distribution and had a nasty tendency to stigmatize commercial sex workers (stereotyped as “Africa’s urban witches”) for spreading AIDS; he also displayed a willingness to privilege traditional, home-grown healing methods despite the fact that some healers and their clients 162 y Chapter 6

attributed the disease to witchcraft.41 In West Africa, the AIDS epidemic almost from the very beginning has been contained in many countries at low seroprevalence rates of 1 to 2 percent or even less, due largely, it seems, to Islamic cultural restraints on sexual promiscuity (despite sanctioning of polygamy), high rates of circumcision, less mobility and concentration of populations in large urban areas, greater economic opportunities for women (hence obviating the need to become commercial sex workers), and the endemic presence of HIV-2, a strain that is apparently far less virulent and infectious than HIV-1. Highest seroprevalence rates in the region, currently at 3 to 4 percent, are in Côte d’Ivoire, Nigeria, and Chad, where there are higher populations of migrant laborers, wider client networks patronizing commercial sex workers, and greater economic instability and poverty.42

We have already seen how many countries in southern Africa are currently laboring under the highest HIV prevalence rates on the continent, which were even higher just a few years ago. Many see this as chiefly due to the region’s legacy of white domination, which lasted the longest of anywhere on the continent. The apartheid regime in South Africa, for example, was not toppled until 1994. Others view the epidemic’s severity here as a product of the silent insidiousness of AIDS, which perhaps has been allowed to incubate unnoticed, whether deliberately or not, for an inordinately lengthy period of time when compared with other regions. But in a way this is not so different from the political question, for the two are closely linked: the dysfunctional regimes that emerged in much of southern Africa after independence were poorly equipped to tackle AIDS. Zimbabwe, for instance, has been ruled dictatorially under Robert Mugabe since 1980 and in addition has been racked by civil war; one-party rule has likewise characterized much of the recent history of Zambia, Malawi, and Tanzania. Swaziland is still anachronistically in the grip of a ruling monarch, King Mswati III.43 And yet democracy is no guarantee of a more enlightened AIDS policy. While the response to the disease under the former apartheid regime in South Africa was characterized by neglect, prudishness, and distrust, under the democratically elected rule of the African National Congress (ANC), the country is still struggling to come fully to grips with its AIDS epidemic.

Other factors amplifying AIDS’s presence in southern Africa include migrant labor associated with the region’s diamond, gold, and copper mines; female poverty and lack of economic opportunity that drive women to resort to commercial sex work; rapid urbanization and population growth, as well as a mutually infective relationship between rural and urban areas; and the severe social and economic disparities that persist throughout the general population.44 AIDS, in turn, has only fed into all these social and economic problems that are helping to drive the disease crisis in southern Africa. Because of its extraordinarily high AIDS y 163

infection and death rates, AIDS has substantially lowered life expectancies in the region (by as much as twenty to thirty years), shifted the age distribution of the population to extremes at either end of the spectrum (AIDS typically targets those between fifteen and forty-nine years of age), and has artificially lowered, and in some cases even reversed, rates of population growth and economic expansion. Some would even argue that AIDS poses a threat to national security in certain countries.45 Since the forces of disease and socioeconomic causes are thereby mutually reinforcing in southern Africa, this has created an almost self-perpetuating epidemic.

South Africa under the former ANC presidency of Thabo Mbeki (1999–2008), aided and abetted by two successive health ministers, presents a unique, some would say indeed bizarre, case of an AIDS policy that has been not only counterproductive but even quite harmful to the cause of AIDS patients in the country.46 This is an excellent example of how just the way in which humans think about and define a disease can have significant and very real biological impacts. The world first learned of Mbeki’s skepticism about HIV being the cause of AIDS in a remarkable public letter to world leaders that he sent out in April 2000, just before hosting the thirteenth international AIDS conference in his home country, where he provided a forum for dissident scientists like Peter Duesberg. Mbeki’s letter was also noteworthy for its harnessing of antiapartheid rhetoric in support of the dissidence cause and for declaring that, since the African AIDS crisis was so different from that in the West in terms of its heterosexual transmission and sheer scale, this in turn necessitated a uniquely “African solution,” a position that, for all the contrasts drawn between their respective responses, was actually quite close to that of Museveni of Uganda as gleaned from his own speeches about AIDS.47 Some of Mbeki’s positions can indeed be said to have some validity, such as that poverty has played a greater role in Africa’s AIDS crisis than previously thought or at least admitted, but in the end these have only served as political cover or posturing for a blanket rejection of Western drugs and vaccines, which Mbeki perceived as being proffered by a pharmaceutical industry that was out to profit from an overhyped epidemic as a new form of racist imperialism. This is in spite of the fact that antiretrovirals had long been proven to not only prolong the lives of AIDS patients but also significantly reduce MTCT, and that they were now being offered by pharmaceutical companies at cut-rate or at-cost prices (some as low as one hundred dollars or less for a year’s treatment, down from about twelve thousand dollars), after they had unsuccessfully pursued a lawsuit (dropped in 2001) in the South African courts to try to protect their drug patents from generic manufacturing. Ironically, by denying or delaying delivery of badly needed ARVs, Mbeki was in fact creating a new apartheid in South Africa, in which AIDS treatment was affordable only to 164 y Chapter 6

some few thousands while the rest of the millions of people living with AIDS

were in effect condemned to an early death. Many also observed hypocrisy in Mbeki’s distrust of ARVs as potentially harmful to AIDS patients while at the same time promoting a home-grown drug, Virodene, which
was
shown to be actually toxic, or in his protests of lack of funds to finance ARV administration even as the government was pouring millions of rands into unnecessary defense spending. Mbeki’s argument was also undercut by the fact that neighboring countries in southern Africa, including Botswana, Namibia, Swaziland, and Zambia, were concurrently implementing successful ARV programs that were reaching thousands of patients, representing 13 percent to as much as half of all those eligible for treatment; such programs were also being pioneered in several countries in West Africa, while in Uganda, the government was able to supply 40 percent of its need-based patients in 2004 by relying on free drugs supplied by international donors (mostly in the United States), whom it actively court-ed.48 Other aspects of South Africa’s AIDS policy, such as health minister Manto Tshabalala-Msimang’s contention that AIDS was a nutritional disease (an idea she seems to have gotten from her adviser, Giraldo) that could be treated with an herbal concoction of lemon, ginger, olive oil, garlic, and beetroot, would be simply laughable if so many lives were not at stake. The silver lining in all this tragic denial has been that it sparked a political activism among AIDS sufferers in Africa who are demanding greater access to treatment, which can be compared to what the gay community achieved a decade earlier in the United States. It started in South Africa with the Treatment Action Campaign (TAC), led by the AIDS activist Zackie Achmat, which forced the Mbeki government to reverse course in 2003 and give at least a verbal commitment to making ARVs more available, and such political mobilization on behalf of AIDS victims has since spread to other countries including Ethiopia, Nigeria, Namibia, and Kenya.

HAART has also been helped along in Africa by generic drug manufacturers, such as the Cipla corporation of India, which have made drug combinations much more affordable as well as easier to take in a single pill format (thus reducing the likelihood of drug resistance emerging from incomplete adherence to regimens) and by philanthropic nongovernmental organizations (NGOs) such as the Bill Gates Foundation and Médecins Sans Frontières (Doctors without Borders) that have provided funds and distribution mechanisms to help administer the drugs.49 The latest UNAIDS report is that, as of 2008, antiretroviral therapy is available to 44 percent of all Africans living with AIDS, up from just 2 percent five years ago.50 This has greatly lengthened the life expectancies of AIDS victims, reduced the number of AIDS orphans and MTCT transmissions, and probably helped to reduce AIDS stigma and reluctance to be tested for HIV, but some worry that it will not do much to reduce new HIV infections since there AIDS y 165

will now be longer windows of opportunity for transmissions, and that the cost of drugs will divert resources needed to address other health and socioeconomic problems, some of which are cofactors of AIDS.51 Most recently, as of 2010, it has also been observed that ART programs in many African countries such as Uganda have stalled or flatlined due to caps placed on outside donations in the wake of a global recession and a shift in priorities toward treating less expensive diseases than AIDS, such as pneumonia, diarrhea, malaria, measles, and tetanus.

This raises the dispiriting prospect that hard-won gains made in the fight against AIDS in Africa will be reversed in the near future.52

A final factor that distinguishes Africa’s AIDS crisis from the rest of the world’s, particularly in the West, is the unique vulnerability of the continent’s women and children to the disease.53 We have already seen that HIV infection rates in Africa are heavily skewed in favor of women, in contrast to what we find in Pattern I countries, and UNAIDS reports that young, teenaged women are particularly vulnerable to the disease in some African countries, such as Kenya, where they are three times as likely to be infected as their male counterparts.54

Aside from their greater biological susceptibility to HIV, women caught up in Africa’s AIDS crisis are also said to be victims of the patriarchal culture and gender inequality prevalent throughout much of the continent, which has not known the feminist liberation movements that have characterized much of modern history in the West, although some would argue that in any case Western-style feminism is simply inappropriate or inapplicable to the different culture of Africa.55 In such an environment, it is claimed, women, both commercial sex workers with many partners and married women with only one, find it difficult to negotiate safe sex strategies, such as using condoms, for both economic reasons (the need to find clients) and social ones (that asking a partner to wear a condom signals a lack of trust). Women, particularly commercial sex workers and widows, have also borne the brunt of the stigmatizing and scapegoating tendencies associated with AIDS in Africa. And yet, being married is of course no guarantee against not being infected by a promiscuous partner, so that marriage itself can be a “high-risk” behavior for women in some circumstances, while the lack of economic opportunities for women in many African countries places single females and widows in conditions of poverty that tend to lead to another high-risk behavior for AIDS, namely, commercial sex work, or casual sex in exchange for “gifts.” Early ages for marriage and sexual initiation, economic pressures to pay for necessities such as school fees, and even alleged rumors that sex with a virgin can cure AIDS have all placed younger women at greater risk.