The New York Review Abroad (54 page)

However, in Uganda, as in much of East and Southern Africa, few families have been spared. In such major cities as Kampala, Gaborone, Johannesburg, Harare, and Lusaka, between 10 and 40 percent of all adults carry HIV. Not only is sub-Saharan Africa in a class by itself when the global spread of the epidemic is considered, but HIV is creating new forms of inequality within particular countries. In this way, HIV has been seen as an indicator of social injustice, both globally and locally. It infests some of the most fragile nations on earth, and increasingly strikes the weakest men and women within them. Meanwhile, infected people and their families are now making up a new social class, excluded from the best jobs and schools and from the warmth of human relationships.

I first visited Uganda in 1993, when I went there to work on an AIDS vaccine project for an American biotechnology company. In 1995, when I left, Uganda was a hopeful, mostly peaceful country. Its president, Yoweri Museveni, came to power by force in 1986, after his National Resistance Army displaced the weak Tito Okello. Museveni promised to redress the corruption and brutality of the governments of Milton Obote and Idi Amin, and he did bring peace to most of the country, although fighting with rebels continues to this day in some northern districts. Museveni has forbidden campaigning
by political parties other than his own National Resistance Movement, but he has encouraged limited forms of democracy. In 1989, parliamentary elections were held, and in 1997, Madeleine Albright hailed Museveni as one of Africa’s “strong new leaders” who had brought order to one of the poorest countries in the world with one of the twentieth century’s most brutal histories.

Uganda is one of the few countries where Structural Adjustment, the World Bank’s economic program based on economic liberalization and privatization, civil service reform and reduced government spending, has been moderately successful.
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The economy grew by about 6 percent a year throughout the 1990s, and Uganda is now exporting coffee, sesame seeds, fish, tea, cotton, and other commodities to the rest of the world. According to the World Bank and the Ugandan Bureau of Statistics, the number of people living in poverty in Uganda fell from 56 percent in 1992 to 35 percent in 2000. While these statistics have been questioned, and poverty in some rural areas may even be growing more severe,
²
for many people life in Uganda has been better in recent years than it has been for more than a generation.

Between independence in 1962 and Museveni’s takeover in 1986, more than a million Ugandans were murdered in political violence and millions more died of starvation and disease. In
What Is Africa’s
Problem?
,
³
a collection of his speeches, Museveni describes how, in the early 1980s, packs of soldiers roamed from village to village, raping women and bashing the heads of crying babies. In Luwero district, where some of the most brutal fighting took place, skulls were heaped up in the forest. By 1986, most of the country’s roads, hospitals, and cities were in ruins and consistent supplies of water and electricity were available almost nowhere.

The economy was run largely by thieves. Idi Amin, who overthrew Milton Obote and took power in 1971, appropriated much of the private capital in the country, including factories and shops, and these were soon destroyed. Uganda’s only export was coffee beans, which were produced by rural farmers and then sold through government-owned companies. The foreign exchange earned through these companies was not used to develop the country but to import whiskey and transistor radios to bribe and placate the army. In the cattle-herding regions of the north, wealthy raiders used helicopters to locate cattle to steal. In the south, along the Tanzanian border, black-market traders got rich smuggling coffee out of the country and importing such essential goods as food and soap at highly inflated prices. Between 1970 and 1985, per capita GDP fell by half.

In 1995, the Kampala skyline still consisted of concrete buildings riddled with bullet holes and streaked with filth, church steeples, minarets, and construction cranes that, I was told, had not moved in more than a decade. There were building lots filled with rubble and piles of rotting banana peels, fed upon by giant marabou storks, scavengers with wings like black shrouds and bald, pink gullets shaped like the trap under a sink. These creatures were rarely seen in Kampala until the mid-1980s, when they came to feed on the detritus left behind by twenty-five years of corruption and war.

Kampala has changed considerably since then. When I visited Uganda again in April 2001, I could see the entire city in its green basin from my hotel window. Mist from cooking fires hung over the slums, and a giant gray cloud sat on the rim of the surrounding hills. Once-derelict streets are lined with freshly painted shops and new hotels and glass office buildings had risen in the center of town. The paralyzed cranes were gone.

Perhaps Uganda’s most noted success during the past decade has been its management of the AIDS epidemic. By the early 1990s, President Museveni became the first African leader to declare AIDS an economic and social catastrophe; a little reluctantly, because in public he is a puritanical man, he acknowledged that people should use condoms to protect themselves. He invited Western charities to establish prevention campaigns and Western researchers to study the epidemic. Condoms are available in most places, and there are radio programs that describe, in precise, even tedious, detail, how to use them. Surveys show that most Ugandans know what HIV is and what they should do to avoid it.

These efforts have been reasonably successful. In 1992, 16 percent of all adults in the country were HIV-positive, but by 1996, only 8 percent were. The proportion of HIV-positive people in Uganda has fallen far more slowly since 1996, and there were even indications that the infection rates rose slightly in rural areas in 1999.
⁴
But even if the decline in HIV prevalence has slowed, Uganda’s relative success in dealing with HIV is unique in sub-Saharan Africa, and international health experts from the UN and other agencies
have claimed that Uganda should be seen as a model for other countries.

However, questions have been raised about whether the fall in the number of HIV-positive people in Uganda really indicates that the epidemic is waning. To understand this, it helps to know the difference between what epidemiologists call “prevalence” and “incidence.” Prevalence refers to the number of infected people in a population, while incidence refers to the rate at which people become infected. In an epidemic, it is incidence that must be reduced. Prevalence falls later, as people either recover or, in the case of HIV, die from AIDS. Incidence is much harder to measure than prevalence, and health departments seldom do it routinely. But epidemiologists conducting smaller studies of particular Ugandan populations have shown that even when prevalence is falling, incidence may still be high, or even rising. In fact, while some regions of Uganda have seen a fall in HIV incidence during the 1990s, others have seen little change.
⁵

The Ugandan HIV epidemic probably occurred in two phases, and this could explain why incidence may be stable or even rising, even though prevalence is falling. The first phase occurred during the war and its aftermath in the 1980s. At the time, many cases of HIV infection probably resulted from what the authors of a recent study politely refer to as “one-off” sexual encounters.
⁶
Rape and prostitution,
in particular, are well known to escalate during war. For example, it is estimated that virtually every woman who survived the Rwandan genocide was raped; at least 20,000 women were raped during the Bosnian war; and at least 250,000 were raped during the 1971 war of independence in Bangladesh. I could find no statistics on rape in Uganda during the civil war in the 1980s, but it is believed to have been very common.

At the time, Ugandan women also saw their families and livelihoods destroyed, and some were forced to exchange sexual favors to provide basic needs for themselves and their children. Since HIV prevalence rates among soldiers in East Africa tend to be very high, it is plausible that HIV first began to spread quickly in Uganda during the turbulent early 1980s. The second phase of the HIV epidemic in Uganda occurred during the relative peace of the 1990s. Today, most HIV transmission actually takes place in longer-term relationships. Indeed, those most at risk of HIV infection in Uganda now are married women who have sex only with their husbands.

The hypothesis that the HIV epidemic in Uganda occurred in two phases implies that HIV prevalence may have fallen in the 1990s because many people infected during the war in the 1980s died of AIDS. Nevertheless, HIV incidence rates during peacetime may still be quite high, although they are probably much lower than they were during the war.

2.

For more than a decade, charities and health ministries in many sub-Saharan African countries have established numerous HIV prevention
programs like those in Uganda, but the results have been mixed. HIV prevention programs in Africa have been far less successful than those for gay men in Europe and the United States, and there has been much speculation about why.
⁷
Some programs have been moderately successful, but the epidemic is far from over anywhere in East and Southern Africa, including in Uganda.

When I was in Uganda in 1995, I myself wondered about the effectiveness of prevention programs. By then, it seemed clear that the vaccine I was studying did not work, and I knew it would be a decade, at the very least, before scientists found one that would protect people from HIV. But Uganda could not wait for a vaccine. At the time, one in five adults in Kampala was HIV-positive, and the virus was spreading along trade routes into the countryside and up into the poor and isolated villages in the north. The AIDS epidemic has concentrated attention on the circumstances in people’s lives that increase the likelihood of unsafe sex, even when people know they should be careful. These circumstances are still poorly understood, but at least two schools of thought have emerged. Either people’s beliefs about condoms, fertility, and disease prevent them from practicing safe sex or they are constrained by larger social conditions in their lives, such as poverty and unemployment, that result in a kind of resignation, a feeling that HIV infection is inevitable, and beyond one’s power to prevent.
⁸

Every African community has a medicine man or woman to whom an estimated 80 percent of African people turn in distress. These
healers are part quack doctor, part psychiatrist, and through their rituals, stories, and medicine they preserve and hand down traditional African culture and beliefs. Perhaps it is through these healers, I thought, that I could understand the mysterious, persistent spread of HIV.

I knew of a charity that was working to train Ugandan traditional healers to become AIDS prevention counselors and I spent a few months working with them, tramping through villages and riding on bicycle taxis into the Ugandan countryside. I met a healer who cured his patients of diseases of the mind and body by placing live chickens on their heads, and another who did it by massaging the soles of their feet. Yet another inspected drops of his patients’ saliva on the surface of a mirror. For many healers, the cure was the sacrifice of a white chicken or, in more serious cases, a goat. The healers told me how the human race had been created when the sun and the moon gave birth to the stars, and then to the earth and the gods. There were gods for love, jealousy, and malaria, but there was no god for AIDS. All of the healers knew about AIDS, but they said they didn’t know where it came from, or how it could be cured. Many of them went to the training sessions the charity conducted, and learned to demonstrate how condoms are worn, and how to recognize when a patient probably has AIDS and should go to the hospital.