Little Hope, Less Help
The epidemic has hit with devastating force--and things will get much worse before they get better
BY MICHAEL D. LEMONICK

As a metaphor for hopelessness, it's hard to equal the AIDS crisis in sub-Saharan Africa. Twenty-four million of the area's people are HIV-positive--70% of the world's infected population. Thirteen million Africans have already died of AIDS, and 10 million more are expected to die within five years. In South Africa, 1 in 5 adults is infected; in Botswana the rate of infection is 1 in 3; in Zimbabwe it is 1 in 4. According to the U.S. Census Bureau, by 2003, AIDS-related deaths will slow population growth in some of these nations to zero, and the population in Botswana, Zimbabwe and South Africa will actually start to decline. Life expectancy by the end of the decade would normally have been about 70 in this part of Africa; as a result of AIDS it will plummet to 30. Said the Census Bureau's Karen Stanecki at last week's 13th International AIDS Conference in Durban, South Africa: "It is hard to comprehend the mortality we will see in these countries."

But terrible as these numbers are, they're bound to get worse. While some of the talk in Durban focused on modest advances in AIDS treatment--and on South African President Thabo Mbeki's flirtation with discredited ideas about what causes AIDS--the central dilemma of the conference was how to fight this voracious plague under the conditions that made the continent so vulnerable in the first place.

One reason AIDS has hit sub-Saharan Africa so hard is that the public health system in many countries is inadequate to deal with even "conventional" disease, let alone a grinding juggernaut like AIDS. According to the World Bank, the region averages $34 per person annually in health-care spending--and far less in places like Nigeria and Kenya--compared with an average of $2,485 in developed countries like the U.S. Less than half the people in the area have access to clean water, and just over half of all children are vaccinated against diphtheria, polio and tetanus. The notion that African countries can somehow buy and distribute the expensive drugs that can prolong life for those infected with HIV--even at the drastically subsidized rates that some companies have promised--is farfetched. Beyond that, the illness and death of so many workers is draining what little strength these already weak economies have.

Another problem is that while AIDS is almost completely preventable, prevention methods must be taught to potential victims. Yet sex education of any sort is rare in Africa, and many people lack even the most basic understanding of how the disease is spread. Upon hearing that AIDS in Africa was mostly a heterosexually transmitted disease, for example, prostitutes in western Kenya started offering clients unprotected anal sex. Since they considered this form of sex "homosexual," they figured they'd be safe.

Even getting Africans to talk about sexually transmitted disease is difficult, says Susan Muguro of the Kenya branch of Standard Chartered Bank, which has begun its own AIDS-awareness programs. The bank's trainers get staff members used to talking about AIDS, safe sex and condoms by making them call out the names of body parts such as penis and vagina. "At first," says Muguro, "people were giggling and blushing. Typhoid wastes us; malaria wastes us; but this disease touches the core of humanity--our sexuality."

Strong leadership from public officials may help, but most African governments have been slow even in admitting they have a problem. It is only in the past 18 months that President Daniel arap Moi of Kenya and President Robert Mugabe of Zimbabwe have used the word disaster in relation to AIDS.

Yet amid the despair, at least two countries have managed to address these problems. Led by President Yoweri Museveni, Uganda started a public AIDS-education program in 1990 that has driven the rate of new infections down dramatically in some places. And Senegal, with its own awareness program, has also cut taxes on condoms and got religious leaders to participate in AIDS education. As a result, Senegal's infection rate is a mere 1 in 50 adults, one of the lowest in Africa.

The notion that developed countries could do more to subsidize the cost of drugs was given impetus by a study reported in Durban last week. Such aid has been dismissed in part on the grounds that patients on these medicines need more monitoring than local health officials can possibly provide. But pilot projects in Ivory Coast, Senegal and Uganda have proved that even poor patients can stick reasonably well to a regimen without constant supervision.

If that's true, then drug companies and Western governments have lost a major excuse for inaction. When the G-8 economic summit convenes this week in Okinawa, AIDS will be a major item on the agenda. And while the African crisis may worsen, it's at least possible that last week's consciousness-raising meeting in Durban could mark a change in attitude--and perhaps even a tiny glimmer of hope.

--REPORTED BY PETER HAWTHORNE/CAPE TOWN AND SIMON ROBINSON/ NAIROBI