Aids epidemic chokes the life out of Southern Africa

Karl Maier in Harare on Zimbabwe's fight to dispel ignorance of the disease

SURUDZAI Rwafa knelt in the dust to pull a two-year-old girl named Tsitsi to her breast. "This little one misses her mother," she said. "She too is infected and will probably die soon."

Mrs Rwafa, a cheery 31-year-old nurse, might seem an unlikely warrior, but she is a soldier on the front line of a war that dwarfs all other conflicts in Africa by comparison. Zimbabwe is now under a devastating attack by the Acquired Immune Deficiency Syndrome (Aids), and it is a battle Mrs Rwafa and other health officials know, at least in the short term, will be lost.

"So many people are dying now that there are funerals all the time. Every day some of the people I go to visit are already dead. They are dying like flies."

All over Zimbabwe health workers and activists are taking up the challenge to educate Zimbabweans how to prevent infection by the human immuno-deficiency virus (HIV) and to care for those who fall victim to Aids. Mrs Rwafa works at an Aids care and awareness project called Dananai ("unconditional love") based at the Murambinda mission hospital in the drought-stricken district of Buhera, about 150 miles southeast of Harare, the capital.

It was the death of her brother Charles, aged 30, that converted her. "When I was directly affected by Aids, that is when I could actually understand how the patients felt - what it really means to be affected by this virus. Somehow when I visit a family, I feel like I am caring for my brother."

Mrs Rwafa spends her days travelling within a 40-mile radius visiting Aids patients in their homes. Her job is part medical, dispensing medicines to ease pain and battle infection, and part psychological, giving victims and their families the sense that someone cares.

Tsitsi's case is typical. She lives with her grandparents near the village of Mudanda. Aids cut down both of her parents and a four-year-old brother in the past year. When Mrs Rwafa paid a recent visit to the homestead, Tsitsi was lying on a reed mat in the sun. She was lethargic, and despite Mrs Rwafa's best efforts, she would not smile: "She has forgotten how to laugh."

Current projections suggest that by the year 2010, one-third of all Zimbabwean youngsters will be orphans, provided they survive their early years. Aids is now the leading killer of Zimbabwean children under five.

The disease accounts for 300,000 deaths per year in sub-Saharan Africa, a rate that is expected to reach 900,000 in five years, according to the World Health Organisation. In Zimbabwe total deaths are expected to pass the one million mark, about one-tenth of the country's current population, by the year 2000. Five years later, the toll could reach two million. An estimated 25-40 percent of the sexually active population is infected. Some projections suggest that in the next 10 years, avergae life expectancy in Zimbabwe could fall from about 55 years to between 30 and 35 years.

The grim statistics of what Zimbabwe's Minister of Health, Timothy Stamps, called "the ripening of the epidemic" tell only part of the story, however. In rural areas such as Buhera, the drastic reduction in the number of young females could cause an economic and social crisis on a scale never seen, since they are responsible for most of the agricultural production and care for children, the sick and elderly.

"More than 90 per cent of the infected individuals are in their economically most productive years, ages 15 to 40," the World Bank said in a 1993 report. Anglo American Corporation, the biggest private employer in Zimbabwe, estimates that 25 per cent of its 15,000 employees are HIV- positive. So great is the death rate, apparently, that burial space in Harare is running out, according to one funeral director. "We may need to consider burying people vertically to save space, or have multi-tier burials."

Nancy Masara, also at the Dananai project, concentrates on prevention. Her focus is on prostitutes, who account for nearly 10 per cent of Murambinda's 4,000-strong population, as well as mineworkers, and the police, up to 50 per cent of whom are believed to be HIV-positive. Armed with boxes of condoms, she and 60 prostitutes she has enlisted as Aids awareness shock troops, known as "peer educators", take their message to the beer halls.

Yet in a culture where prostitution and male promiscuity is widely accepted, critics have suggested that "peer education" programmes which focus on women are missing the point. The WHO estimates that there is a 100-1 chance of an infected man transmitting HIV to an uninfected woman in a single act of unprotected sex, compared to 1,000-1 when the woman is infected and the man is not. Married women, in particular, are vulnerable. In Africa, an estimated 80 percent of HIV-positive women are monogamous, while 80 per cent of the HIV-positive men have multiple sexual partners. "For most women, the major risk factor for HIV infection is being married," the UN Development Programme said in a recent report.

Prostitutes in Murambinda charge an average of 10 Zimbabwe dollars, about 80p, to sleep with a client, and about pounds 2 for a whole night. Some said that the Aids awareness campaign had convinced many of their clients to use condoms. But they admitted that resistance remained strong, particularly among the 50,000-strong Zimbabwe National Army, where health officials estimate the HIV-infection rate to be at least 50 per cent. Mr Stamps has publicly criticised soldiers for spreading Aids among young girls. One doctor blamed the myth that sex with a virgin would cure the infection for a series of rapes of young girls in the affluent northern Harare suburb of Mount Pleasant.

Health officials reckon that Aids began travelling 20 years ago down the transport routes from Central African countries such as Zaire and Uganda through to Kenya, Rwanda, Tanzania, Malawi and Zimbabwe. With its excellent roads, history of migrant labour, and culture of male sexual promiscuity, Zimbabwe was particularly vulnerable. The next target is South Africa, where some estimate that as many as 550 people are being infected each day.

Prior to 1986, the annual reports of Murambinda mission hospital did not even mention Aids. Now Monica Glenshaw, the acting district medical officer in Buhera, estimates that 25 per cent of the hospital staff are HIV-positive.

"What I really notice is the increase in the number of graves you see around everyone's homes in the rural areas." The saddest aspect, Dr Glenshaw said, was that the Aids epidemic had become a normal part of life, accepted as just another killer like malaria. "I just keep telling myself that my patients are not going to live as long as they used to, but I still have to care for them." The scale of the epidemic shocks even the most experienced observers.

"When I decided to work in Africa I believed I appreciated how bad the Aids problem was," Richard Rigby, a UK doctor, wrote in the British Medical Journal in June. "Now I do not believe anybody really does."

Mrs Rwafa does. When she travelled to visit one of her patients in the village of Vhiriri, a 25-year-old woman named Sylek, a dozen relatives were sitting around fires preparing food as she drove in. Sylek had died three days before, leaving behind two children. One of her elderly aunts was confused. "Why are all our children dying?" she cried out. "Why are the young ones dying and leaving us older people with their orphans?"

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