Deborah Orr in Mozambique: A deadly silence

Ernestina Mrta has a nice little set-up by the material standards of any 16-year-old in the world. She's the sole owner of a stylish little Modernist bungalow, decked out in cool pastels, solidly furnished, and with maybe half an acre of fertile garden attached. It's all seen better days, admittedly. The paint on the house is peeling and the land is no longer cultivated. Yet compared to some of her neighbours, who are barely subsisting in the most basic of straw or mud huts, Ernestina is a young woman of considerable substance.

This shy, sweet schoolgirl is quietly and justifiably proud of her home, and its contents. Glasses and crockery are displayed in the glass-fronted cabinet, rubbed till they sparkle, valued and cherished. Her own childish treasures are placed on top, resting on crocheted doilies. Barbie is still in her box, admired more than played with. A watercolour painting set, resplendently gay in magenta-coloured plastic, has seen a little more action. But it, too, is propped up artfully, perhaps bringing more joy as a trophy than as an ephemeral means of whiling some time away in play.

The leather sofas and armchairs are arranged in a rectangle around a low table, as studiedly inviting as the lounging area of a Caffé Nero, and in just the right place for the music from the powerful-looking sound system to be appreciated in the most satisfactory fashion (were it not long bust). The large dining table is draped with a cloth, even though, in truth, this young lady has no idea where her next meal might be coming from.

There are glass-framed pictures arranged on the walls. Ernestina's mother and father glower out of black-and-white portraits, looking as uncomfortably formal as they might have in daguerreotypes from the 19th century. Nelson Mandela smiles down gently and beneficently; in the just way the world expects Nelson Mandela to smile.

There's a lovely, faded colour photograph of the house when it was new and freshly painted, looking more Miami than Mozambique, under the aqua skies that Bob Dylan offered a paean to in his romantic song about this vast, strange, compelling country. The skies aren't "aqua blue" today though. They are low and lowering, bearing down on Ernestina and her house as threateningly as Ernestina's own dark troubles bear down on her.

Back to Ernestina's gallery though, for her pictures tell a tumultuous story. Here on the walls of this little house hangs the tragic, ghastly story of this sad, scared orphan's life.

What a dynamic, ambitious, bunch the Mrtas must have been, for they were quick off the mark in the 1990s when the civil war ended and travelling to work in South Africa's gold mines became feasible. All the men went, Ernestina's father and his brothers, and herein lies the source of the family's affection for Mandela, and of course, of its locally remarkable wealth.

Herein lies the source of its disaster, too, because in this town, Chokwe, in this province, Gaza, close to South Africa's border, Aids is more prevalent than in almost any other part of the country, for the simple reason that the migrant workers brought it here. Ernestina's father died first, in 2000, then one uncle, then another. Her aunt died, then her mother, then her two brothers, then one of her sisters. Ernestina still had one sister left. But in a cruel little codicil she went a few weeks ago too. She did not die of an Aids-related illness, but was run over by a car while out for the evening with friends. Ernestina is quite alone now, her assets probably making her more rather than less vulnerable to the abuse and exploitation that are hallmarks of the lives of Mozambique's 380,000 Aids orphans.

The most telling thing of all is that not one of Ernestina's family members was ever diagnosed with HIV, or treated for it. There is still huge stigma attached to the disease here, and people just don't want to know about it. When we were driving to Ernestina's house, a popular Mozambiquan song came on the radio, in which we could hear mention of "Sida", Portuguese for Aids. When we asked our driver what the lyrics translated as, he told us this:

"When I'm out with my friends, we all talk about Aids,

When I'm out with my girlfriend we talk about Aids,

Plenty of people making cash out of Aids,

Filling their bank accounts with money."

Maybe these snotty little songsmiths had Ernestina Mrta in mind when they wrote their cynical little ditty of denial, for the idea that Aids in Mozambique is some conspiratorial money-spinner is no less absurd than the proposition that the virus has been good to this abandoned young woman. Sure, there must be a few private doctors treating Mozambique's small but burgeoning middle class with expensive discretion. But the shame of the well-off and the educated is part of Mozambique's problem. Aids campaigners absolutely long for a public figure or a parliamentarian to break the silence. So far, in the face of much lobbying, no one has been tempted.

It's quite Men In Black generally, Mozambique. Or maybe a bit Fawlty Towers. It has undergone the familiar cycle of repressive, asset-stripping colonialism (it was a major slave trade hub); of bitter struggle for independence (the Portuguese pulled out, almost overnight, in 1975); of headlong collectivisation by a USSR-sponsored government (that left the country functionally bankrupt by 1983); and a civil war considered deeply nihilistic even by Africa's exemplary standards (it only ended in 1992). Now, it ranks as the world's 9th poorest country, with a life expectancy of 37, and a hefty 50 per cent of the state budget dependent on aid.

Yet no one ever seems to talk about this stuff, any of it. Mozambique, in the south anyway, comes across to the visitor as together, efficient and forward-looking. The people seem positive, busy, purposeful, and markedly enthusiastic about social democracy. The infrastructure's pretty good, the economy's growing at a healthy 7 per cent each year, and progress towards important developmental goals like universal free education is moving at a cracking pace. No one looks back.

It's as if Will Smith's been round zapping everybody with his memory reprogrammer, or John Cleese has silly-walked his way across the country, manically instructing the population not to mention the war. Maybe this is a good thing. Or maybe the horror and the anger is repressed, waiting to seep out later. The present trouble is that no one mentions Aids either, even though it is the single greatest threat - among many - to the future of the nation. For those who have the virus, or suspect they might have, this conspiracy of silence, this culture of rejection and revulsion, brings an added burden. Those who are brave enough to face reality, and seek help, face a great deal of social disapprobation as well. It's hard to admit that you're HIV+ in Mozambique, which only makes a fraught situation all the more punishing for the individuals facing it.

At the Xai-Xai Health Centre in Gaza's provincial capital, the silent, waiting women are gaily dressed. But the impression they make is drab, nevertheless. They all have the same haunted look on their faces, and the same helpless droop in their bodies. Heads slightly bowed, huge, unblinking eyes staring forward, they sit in patient, placid dread. They are sorrowful, defeated, baleful, traumatised. It's no surprise, of course, that pregnant women and nursing mothers should find themselves unhappy to be attending clinics specialising in the prevention of maternally transmitted Aids. The pressure is greater yet because they risk rejection even by coming here, or even destitution. It is by no means unusual for an HIV+ woman to be chucked out of her husband's home. But the hypnotic uniformity of the expression of their individual misery is still an eerie sight to behold.

Clearly the woman are all suffering from depression as well as from HIV, and it's a tribute to the architects of Mozambique's public health system that this crushing fact is recognised. Jacinta Munguamba, 43, is the in-house clinical psychologist at the health centre, and she's worked in Aids counselling for nearly all of her career. The reason for her specialisation is simple. No one else really gets therapy in Mozambique, with the exception of children with learning difficulties. Her work is tough now, she admits. But in earlier times there was nothing to offer but testing and counselling in preparation for the inevitable, even though all the staff knew that drugs were available if only they could access them.

That's what makes the miasma of misery that hangs over this place so striking, however understandable its cultural sources may be. These women are, relatively speaking, lucky, lucky, people. They are in the vanguard of what campaigners hope will be a pan-African shift in the treatment of Aids. Only 5 per cent of Mozambique's 146,000 HIV+ pregnant women are receiving medical support to help prevent mother-to-child transmission of the virus, but that's a vast move forward from two years ago when no such joined-up effort existed. These ladies are doing the right thing, in the right place, at the right time. There's every chance that they and their children will thrive, like no African generation before them has.

It's clear that 24-year-old Joana Adrrano doesn't see it that way, for she is as inscrutably numb as her fellows, her tenderness for her six-month-old son, Feliz, communicated hesitantly, with achingly careful diffidence. Maybe she simply does not dare quite yet to love him as freely as she would like to.

Joana, dressed smartly in Western clothes, an old, gouged scar on her nose and cheek offering a lop-sided glimpse of violence long past, talks of her troubles in the same unaffected manner with which she attends to her baby. Animation strikes only when she is asked what her husband does. Breaking into a beam of spousal pride, she announces that he is a Christian minister. Her irrepressible smile is without irony, even though the assumption has got to be that her man has been spreading a good deal more than the word of God.

Joana knows she is HIV+ and healthy, though her son has not yet been tested. In the capital, Maputo, babies can now be given a pin-prick blood test at birth. Here in Xai-Xai such simple technology is not yet available, and children are still checked out for antibodies when they are 18 months old (any earlier and the mother's antibodies still register). But because she and her son received a dose of the antiretroviral drug Nevirapine at delivery, and because she is following the clinic's advice to breast-feed exclusively for the first six months and no longer, the possibility of Feliz having the virus is tiny. Without intervention, his chances of being HIV+ would have been one in three.

Though adults can now be treated for HIV with relative ease, it is much, much trickier with children. Mother-to-baby transmission has been pretty much eradicated in the West, in large part due to routine redress to Caesarean section, so there is no market-driven incentive for child-friendly drugs to be developed. Adult dosages, available in combination pills, are too toxic for children weighing less than 12 kilos. The drugs have to be given in three separate syrups, each in different syringe-measured amounts, with food, at the same time twice a day, and with each careful combination varying scrupulously, depending minutely on the exact weight of the child.

In a country like Mozambique, with 70 per cent of the population rural subsistence farmers, the vast majority of adult women illiterate and access to medical intervention still extremely difficult in the parts of the country with limited infrastructure, it's hard to get across to carers what is expected of them, even though the consequences of an inaccurate dosage are serious. Resistance builds quickly if the dosage is wrong, and the second-line treatment costs 10 times as much and involves, in addition to syrups, pills that have to be crushed or cut up (although GlaxoSmithKline has recently agreed to start scoring the tablets it manufactures, allowing them to be more easily divided). The second-line treatment is much more toxic for children.

Maputo Central Hospital represents the highest level of the referral system for all diseases affecting children in Mozambique. It's on the wards of the paediatric unit here that the consequences of this convoluted treatment of Aids in children can be most graphically witnessed.

Obviously, the hospital deals with increased likelihood of malaria, respiratory illness and the full range of opportunistic infections endemic in the tropics that a compromised immune system invites. But it also has a specialist malnutrition ward, in which more than 50 per cent of the children admitted are HIV+. Marta Mongane has ended up here with her starving granddaughter, Jennifer Tembe. Marta's own daughter died of Aids a couple of years ago, and, as is so often the case, the old lady has been left to care for her grandchild as well as herself. Marta has little in the way of resources to do so, especially as the facial disfigurements of Aids-related herpes-8 mark her out so obviously as a person with Aids, and therefore a pariah. She has not heard from her son-in-law for a while, but assumes, probably wrongly, that he's still working in the gold mines across the border.

Then there are the extreme reactions to the antiretroviral treatment itself. Nevirapine, particularly, can trigger Steven Johnson Syndrome, which causes excruciatingly painful burn-like blisters all over the body, while cancer in HIV children runs at 20 times the normal rate. Up against this lot, babies with HIV have only a 50/50 chance of lasting more than a year. This huge attrition rate accounts for the fact that 80 per cent of Mozambique's 99,000 under-15s with HIV are children under five. It is all this that makes prevention of mother-to-child transmission such very good sense, and it is why Unicef is raising funds to roll out the treatment all over Africa.

The director of the paediatric hospital is the formidable Paula Vaz, who trained for a time in France and runs a tight, tight ship back here in Southern Africa. She explains crisply that the children with cancer are all treated with chemotherapy, because the radiotherapy machine broke down 16 years ago and has never been replaced. She is philosophical about such matters, and asserts also that the availability of drugs and equipment is the least of her problems thanks to good government support and the commitment of a number of NGOs. She particularly emphasises the achievements of the Clinton Foundation and Médecins Sans Frontièrs, both of which did so much to break the patents on Western Aids drugs, allowing developing countries to produce cheaper generic medicines. Most of the drugs used in the hospital come from India.

Paula's main worry is human resources. She wants to see a massive expansion in paediatric clinics across Mozambique, and is hopeful about plans to establish centres of excellence like hers at hospitals in Beira and Nampula. But she worries about where the skilled people needed to administer such treatments will come from, in a country already struggling to recruit highly educated staff.

The doctor's fears are well-founded, in the short term at least. Since the launch of the national Prevention of Mother-To-Child Transmission programme in 2002, the number of specialist clinics has increased from eight to 113. The aim is to provide the services in 375 health centres by 2009. But there's a real worry that the plan will suffer in the same way as schools expansion has, with the supply of adequately trained staff unable to keep pace with demand. Amid all the fear and loathing, and the very real practical problems, Mozambique has one resource that even seasoned African campaigners are keen to emphasise is quite unusual - its small but vocal army of "activistas". Unicef, active in Mozambique for 30 years, sees this socially democratic tendency as a massive human asset that can be nurtured to great effect, and works hard to locate and support on-the-ground activity from socially conscious Mozambicans.

At the central market in Maputo the skies are aqua blue again, and Alvim Cossa, assisted by his deputy, Dinis Chemnene, is setting up his travelling community theatre for a performance. These two men, modestly supported by funds from Unicef, go round the country to schools, outlying villages and any other place where there's room to put up a simple backdrop, rope off a spot to make a stage, attract a crowd, and make a stab at awareness-raising.

Alvim picked up the idea in Brazil, where he went to study drama, and returned to establish his own Grupo de Teatro do Oprimodo, or Theatre of the Oppressed, in Mozambique. The idea is to encourage audience participation by inviting bystanders to get up on the stage and act for themselves. Today, the group is challenging the gender stereotypes that keep ordinary African women dependent and submissive, and account to a large degree for their disproportionate representation as victims of Aids. (In Mozambique, 58 per cent of the infected population are women, and girls aged 15-19 are three times more likely to be infected than boys in the same peer group.)

At first, the actors do a skit that shows a woman in traditional headgear running round doing all of the housework and childcare, while her husband busies himself with getting ready to go out for the evening. His wife has washed and ironed his crisp grey shirt for him, but when he shrugs it on, a button is missing. She breaks off from her work and sews it back on as he stands there, chin arrogantly raised to give her room to ply her needle. Then, women in the audience are invited to don the headscarf, take to the stage, and suggest for themselves other courses the story might take. Girls come forward, eager to tell this husband surrogate where to get off, egged on by a roaring crowd.

While the community involvement of Alvim and Dinis is particularly vivid, there seems to be some measure of local activism in even the most unpromising of situations. At Xai-Xai clinic too, this tendency towards community self-help was apparent, in the blue-T-shirted forms of Thelma, Nelia, Samuel and Ruth. All four are students in their early 20s, who first encountered Aids services when they came in to be tested themselves, and volunteered as activistas because they "wanted to stay involved". They are trained to work specifically with teenagers, offering pre- and post-test counselling. All of them say that they are committed to working in Aids awareness in the long term.

Attempts to find out exactly where in the Mozambican societal set-up this enthusiasm for good works has come from are met with mild bemusement and the hesitant suggestion that it is connected to the socialist ethos of the Frelimo Party, which coalesced in 1962 as the Mozambique Liberation Front, operating from Tanzania and fighting for independence.

Frelimo survived the civil war against right-wing Renamo (which was backed by South Africa and Rhodesia) because it had provided bases for the African National Congress and the Zimbabwe African People's Movement. It has now survived all three of Mozambique's democratic elections as well, although not without disavowing Marxism at the start of the democratic experiment. Even so, it seems far-fetched that community activism could be quite so ideologically motivated.

In the case of 32-year-old Amos Sibonbo, though, the connection is clear, as his life in activism began when he joined the Continuadores, Frelimo's youth movement, at 14. When the government decided in 1997 that it would adopt a strategy of devolving the building of Aids awareness to civil society, Amos was one of the young people who was selected to be trained up in Aids awareness. His own Aids awareness quite clearly improved as a result, because he went off with some friends and got tested. Amos and five of his friends came up positive, and formed a self-help group called Kindlimuka. So far he has helped to found another 27 similar groups across Mozambique and runs Rensida, an umbrella group that co-ordinates the self-help meetings. He appears to have some involvement in Aids campaigning at every level - locally, provincially, nationally and internationally. His commitment is awesome.

He is also the only man we have come across in Mozambique who is willing to talk frankly about his own HIV status. Glowing with health, gently confident, and sporting cheekbones like geometry, he's quite obviously a living, breathing advertisement for antiretroviral heartiness.

He's outspoken and lucid on pretty much every aspect of the problems facing his countrymen. He talks with impatience about the parliamentarians he has asked to go public about their own experience of HIV, although, quite rightly, he stops at naming names. He speaks despairingly of the African man's dislike of condoms, and sighs as he explains that they now also see their purchase as a signal that they are carriers, rather than as a sign that they are responsible men who understand the risks that face them.

He's good on the psychological workings of denial as well, explaining that people fail to "internalise" the fact that they have HIV, and actually prefer to tell themselves that they are cursed. He dates this resistance back to the message in the 1990s, which was a stark one - if you have Aids, you die - and made a strong, judgmental link between Aids and dangerous and shameful behaviours. He's most passionate about the work he does in schools, talking to children in the 10- to 14-year-old "window of hope", which he says is the time, just before they become sexually active, that provides the best results. A few more men like this, one feels, and Mozambique could turn things around.

Even at the most basic level, there is often some sort of "activista" support, though it may not have quite the political and social sophistication of Amos' approach. Young Ernestina, vulnerable as she may be, has people around her who care. She is not quite alone in the world, because Adele, her volunteer "ouvinte", or listener, looks in on her and 19 other local orphans every day to see how they're doing. If they have no food, she feeds them. If they are down, she cuddles them. If they need to talk, she listens.

When there are difficulties that Adele can't handle herself, then she reports them to Amelia, another volunteer, who acts as liaison between the local ouvintes and Vukoxa, the local charity that co-ordinates them. The two women work for no pay, although Amelia gets a bicycle so that she can get around her area. The original idea behind Vukoxa was to provide neighbourhood support for the elderly, and ensure that the most isolated of old people did not end up forgotten. But as more and more Aids orphans have ended up under the roofs of their grandparents, Vukoxa has become involved in providing direct assistance to child-headed families and also in campaigning to challenge the stigma and discrimination that is suffered so routinely by families stricken with Aids.

It is Adele and Amelia who encourage Ernestina to keep on walking the seven kilometres to school every day, furnish her with the basic necessities of life she needs to do so, and exhort her not to sell her belongings and her house, because "they are her future". They hope for further education for her, a decent job, a good marriage. They are protective of her, affectionate, and as concerned for her as any family member might be. They are lovely, lovely women, and they need and deserve all the help that we can offer.

To help children affected by Aids in Mozambique and around the world, donate to Unicef's campaign "Unite for Children, Unite against Aids", by calling 08000 379 797 or visiting www.unicef.org.uk/aids

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