The wireless balanced near his ear is the only indication that he was once a man of substance, a cultural officer in local government. He accepts the medicines offered him - for Kaposi's sarcoma, diarrhoea, oral thrush; the familiar symptoms of Aids - but cannot remember the doses. His mother assumes the responsibility with desperation in her eyes. Soon she will have survived all her children. Already she has survived many of her grandchildren.
Outside, Dr Albert Faye of the French charity Medecins du Monde looks at his assistant. 'Did she understand?' His assistant shrugs. What alternative was there in a family where only the very old are left?
At the next stop, a beautiful young woman, fine-boned, straight-backed and proud, cradles a dying child. She moves only to rock him and seldom takes her eyes from his.
Slowly, painfully, the facts emerge. Her husband has Aids. Two previous wives are dead and another is sick. She herself has fevers. Her child, a tubercular two-year-old with a strangely swollen belly, has never been well. There will be no more hospital for him, she says firmly. Time and again she is told, with great patience and gentleness, that he will surely die at home. No more hospital, she repeats.
'She dislikes the hospital because she feels stigmatised,' a counsellor explains later. 'Instead of going to the hospital yesterday to collect medicine for the child, she took him to a dispensary where they put him on a drip. But these dispensaries are inexpert and they infused him too quickly. That's why his stomach is distended. She knows the child will die and she thinks she is sick. She has had enough.'
This is Bukoba - capital of Kagera district in northern Tanzania, heartland of what the Sunday Times has called 'the plague that never was'. Statistics compiled by Dr Japhet Killewo, head of epidemiology at Dar es Salaam University, show that 24 per cent of adults in Bukoba town were HIV positive at the last count. A survey carried out by Medecins du Monde at Bukoba hospital between August and October last year found 19 per cent of pregnant women were infected.
Seen from here, claims that HIV is not lethal seem at best bizarre and at worst dangerous. Suggestions that heterosexual Aids is largely a myth are denounced as 'criminal'. African voices tell you they are dying as never before; that medicines that once cured malaria, TB and diarrhoea no longer do; that sex is the cause of this sickness.
On a rainy afternoon before business picks up, bar girls, the highest risk group in Bukoba, besiege a foreigner. They have heard there is a female condom and they want it. Men, they say, are pig-headed about protection. Especially rich men. They gasp when told that a 'medically trained charity worker' in Kagera has been quoted as saying she will sleep with anyone who is HIV positive to prove she will not be infected (see below).
'I'd say that means she is already infected]' they say, laughing. And then, aggressively: 'Let her come]'
Traditional healers prevaricate when asked if they can cure Aids. 'It may be necessary to send them to hospital to seek higher medical advice,' admits Bassajja Balaba. 'I can only give symptomatic treatment.' His father, Gideon Makumbi, snorts. 'Aids is incurable. That is a fact. It is like sweeping
back the ocean using a broom. Once I had 25 children. Now I have five. I have to sit and watch them die until I die and it is over.'
The night ferry from Bukoba docks at Mwanza on the southern shore of Lake Victoria in early morning, packed with young men trading bananas and sugar cane. The African Medical and Research Foundation (Amref) fills the lavatories with boxes of condoms in the knowledge that 48 per cent of Mwanza's bar-girls are infected and the mortuary at Bugando Medical Centre is overflowing.
'There are eight fridges and when you open them you find three bodies inside,' says Mr Arnoud Klokke, head of pathology. 'The majority are Aids patients. We put air-conditioners into the freezer room a year ago so you could at least keep bodies there for one or two days without them deteriorating too fast. Twice a week the municipality comes with a huge garbage truck to collect the bodies that are uncollected.'
Aids is changing even death in this part of Africa, where the first HIV-related fatalities were recorded a decade ago. 'Funerals used to go on for seven days,' says Paschasia Rugumira, a nurse. 'Now it's three.' Across the border in Uganda, many families are bringing relatives home from hospital just before they die, no longer able to afford the transport cost of corpses. Bicycles with skeletal figures strapped to wooden seats above the back wheel are a common sight wherever there is a hospital or clinic. Funerals and memorials are frequently combined - as they never were before - and often less well attended: too many working days are being lost in mourning and travel is expensive.
In Kampala, so many civil servants are dying that the government is considering withholding funeral expenses. 'The government traditionally provides the coffin, transport and cloth for the burial,' says Mary Muduli, Acting Commissioner for Expenditure.
'Now it is not practical; the numbers get bigger and bigger every day. For the moment we are just trying to manage, ministry by ministry, the best way we can. This ministry is recommending that families should pay for funerals if they can.'
At Kitovi hospital in southern Uganda's hard-hit Rakai district, a counsellor says people are even crying less than they used to. 'In three years, I've been to five burials on a staffer's compound,' she says. 'A sixth member of the family is now sick. Two of the dead were children. How many tears does one person have?'
Already 1.7 million Ugandans are infected in a population of 17 million and researchers say the epidemic has not yet peaked. The Virus Research Institute at Entebbe has found that HIV accounts for 50.5 per cent of all adult deaths in a region where 5 per cent of the population is infected. Aids is the principal cause of adult death and the fifth largest
cause of child death at Kampala's largest hospital, Mulago, where HIV infection often underlies the greatest paediatric killers - malaria, diarrhoea and tuberculosis.
'Children with chronic diarrhoea and pneumonia don't get better,' says Dr Hanny Freisen, a paediatrician at Rubaga hospital. 'They don't grow even if they get food. And the graphs are rising. Recently, I told a 25-year-old girl she was positive and was amazed to hear her say: 'It's not so bad. So many girls in my village have died already. At 25 I thought I had the world in front of me.' I sent her home with that for Christmas]'
In Tanzania, where HIV infection has brought a resurgence of once-controlled epidemics such as tuberculosis, the Ministry of Health predicts that 2,400,000 people will be infected by the year 2,000. Child mortality, which decreased steadily for 20 years, is again increasing.
'Aids in Africa is an epidemic of enormous magnitude comparable only with tuberculosis in England at the turn of the century,' says Daan Mulder, head of the Virus Research Institute, which has shown that young people who are HIV positive are 87 times more likely to die prematurely than those who are not. 'In many urban areas there is already a massive spread in adult populations outside high risk groups.'
As HIV infection extends into the general population, Aids is placing new strains on economies already burdened by the structural adjustments demanded by the International Monetary Fund. Skilled workers who cannot be replaced are dying; meagre resources are being diverted from development to relief: treatment is replacing prevention, at great expense.
'Government capacities are definitely being impacted on,' says Mrs Muduii. 'In one month, three senior economists have died in this ministry and I don't see how anyone expects us to replace them. There aren't too many well-trained people around here.'
'A great number of our doctors have died,' says Dr Bonie Tindyebwa, a paediatrician at the Mulago hospital. 'Nurses and midwives have also died in great numbers.'
Research by the Aids Information Centre in Kampala indicates that worse is yet to come. Despite vigorous safer-sex campaigning, some of the highest infection rates in the city are in the area of Makerere University, the institution that produces the country's elite.
There is similar attrition
in Dar es Salaam. 'We are losing a lot of people now, especially the chief executives,' says Dr Swai, head of Tanzania's National Aids Control Programme. 'There is no sector that would say it hasn't been touched. Mention any ministry or state company and they will tell you they have lost someone.'
Although HIV infection is devastating many urban areas with wealthy, mobile populations, the epidemic varies in strength and in many rural areas is still relatively minor. Limiting the spread in these areas, where a majority of Africans live, is one of the main challenges facing governments. Amref researchers believe the best line of attack lies in targeting high-risk groups that spread the virus. Others concentrate on community development in the conviction that HIV is in large part a poverty disease, compounded by lack of education and the inability of women to negotiate sex.
The head of counselling at Kitovi hospital asked a group of young women to list the reasons why they had sex. The main reason was 'gifts' - school fees, clothing, extra tutoring. Prostitutes regularly tell counsellors they'd rather die of Aids tomorrow than starve today.
Once implanted in a community, HIV creates a vicious circle of poverty by attacking the strongest members - those responsible for families, labour, education, even ideas. Productive time is lost caring for the sick. Money that would have been invested is diverted.
Before Aids, Zimwe, a trading station near Lake Victoria, had four schools. Now it has one. Teachers fled and died, buildings fell into disrepair, morale collapsed. 'I have lost eight sons and you tell me to go and dig]' an old man told an agricultural adviser. 'What for?'
Epidemiologists look on the bright side: if 10 per cent of the population is infected, 90 per cent is not. In the last decade, they say, agencies directed by the World Health Organisation and national governments have implemented large-scale blood screening that covers roughly half of all donated blood. Programmes aimed at high-risk groups using instructors from those groups have had some success among truck drivers and prostitutes. The stigma attached to Aids is decreasing, thanks in large part to the extraordinary work of African non-governmental organisations, and discussion of sex is no longer taboo.
But Aids control is still confined largely to health ministries; health structures are grossly inadequate; churches still campaign against condom use and soldiers rape with impunity; and, despite some caution, there is little evidence the epidemic is significantly changing the way of life in sub-Saharan Africa - except among those whose peers are dying.
'We have a fairly good understanding of the epidemic and modes of transmission, and I refute ideas that nutritional and environmental factors are responsible,' says Daan Mulder. 'But we haven't got close to knowing how to prevent the disease in large sections of the population. It shows how hard it is to change behaviour.'
This is especially true of economic war zones such as Kagera and Rakai, where only half the children are in school and young men drown themselves in pombe, an alcoholic brew concocted from bananas and sorghum, and waragi, a lethal distillation of pombe.
'People are continuing with their old ways, especially when they get drunk,' says Joseph Jemba, a Rakai shopkeeper who agreed to sell condoms - alongside jerry-cans of pombe - after his son, sister and brother-in-law died of Aids. There are also disturbing new ways. The epidemic has brought one behavioural change - vastly increased abuse, and rape, of children. Orphans are especially vulnerable to relatives, neighbours and teachers.
In Rakai, a 15-year-old caring for six siblings recently gave birth. Kitovi hospital has received many rape cases, including a child of three attacked by a 17-year-old neighbour. In Mwanza, the age of girls who sell eggs and chips - and sometimes sex - on the streets has gone down from 17 to 12 or 13.
'One of our girls is having three sexual encounters a day,' says Mustafa Kudrati, co-ordinator of the children's rights group Kuleana. 'Young girls are thought to be safe.'
Government officials, doctors and aid workers refute charges that too much money is spent on Aids control and regret, bitterly, that these accusations coincide with signs of donor fatigue.
'A statement that HIV draws money from other diseases is a cheap, unqualified statement,' says Mulder. 'There's good evidence that the most cost-effective way of preventing the Aids epidemic is to intervene as quickly as possible, while there is no spread into the general population.'
'Any money you invest now in Aids control is much better spent than 10 years ahead,' agrees Dr Ulrich Laukamm- Josten of Amref.
'There is a natural curve in this epidemic. It will reach a plateau. You can debate whether it will be 10, 20 or 30 per cent, but it's never beyond 30 per cent. As a donor you should say: this is an exceptional event, the number one health problem. So for a period - five or 10 years - you concentrate on control, primarily prevention.'
Social workers say children need more help - not less - and express grave fears for uninfected children who are not being cared for. 'The social welfare sector is so under- resourced, it is not able to do very much,' says Chris Roys, Save the Children's social work adviser in Rakai. 'I'm worried about a generation of children growing up experiencing so much sickness and death; perhaps lacking education and skills that would enable them to survive in a traditional way.'
The director of WHO's Global Aids Programme points out that a basic HIV prevention programme for 1990, for all developing countries, would have cost a twentieth of Operation Desert Storm. But that was Kuwait, this is Africa.
(Photographs omitted)Reuse content