Tributes to Sheldon Seevak

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Posted November 16, 2005 in AIDS
Mark Schoofs, "AIDS: The Agony of Africa," Village Voice (1999)

Penhalonga, Zimbabwe—They didn't call Arthur Chinaka out of the classroom. The principal and Arthur's uncle Simon waited until the day's exams were done before breaking the news: Arthur's father, his body wracked with pneumonia, had finally died of AIDS. They were worried that Arthur would panic, but at 17 years old, he didn't. He still had two days of tests, so while his father lay in the morgue, Arthur finished his exams. That happened in 1990. Then in 1992, Arthur's uncle Edward died of AIDS. In 1994, his uncle Richard died of AIDS. In 1996, his uncle Alex died of AIDS. All of them are buried on the homestead where they grew up and where their parents and Arthur still live, a collection of thatch-roofed huts in the mountains near Mutare, by Zimbabwe's border with Mozambique. But HIV hasn't finished with this family. In April, a fourth uncle lay coughing in his hut, and the virus had blinded Arthur's aunt Eunice, leaving her so thin and weak she couldn't walk without help. By September both were dead.

The most horrifying part of this story is that it is not unique. In Uganda, a business executive named Tonny, who asked that his last name not be used, lost two brothers and a sister to AIDS, while his wife lost her brother to the virus. In the rural hills of South Africa's KwaZulu Natal province, Bonisile Ngema lost her son and daughter-in-law, so she tries to support her granddaughter and her own aged mother by selling potatoes. Her dead son was the breadwinner for the whole extended family, and now she feels like an orphan.

In the morgue of Zimbabwe's Parirenyatwa Hospital, head mortician Paul Tabvemhiri opens the door to the large cold room that holds cadavers. But it's impossible to walk in because so many bodies lie on the floor, wrapped in blankets from their deathbeds or dressed in the clothes they died in. Along the walls, corpses are packed two to a shelf. In a second cold-storage area, the shelves are narrower, so Tabvemhiri faces a grisly choice: He can stack the bodies on top of one another, which squishes the face and makes it hard for relatives to identify the body, or he can leave the cadavers out in the hall, unrefrigerated. He refuses to deform bodies, and so a pair of corpses lie outside on gurneys behind a curtain. The odor of decomposition is faint but clear.

Have they always had to leave bodies in the hall? "No, no, no," says Tabvemhiri, who has worked in the morgue since 1976. "Only in the last five or six years," which is when AIDS deaths here took off. Morgue records show that the number of cadavers has almost tripled since the start of Zimbabwe's epidemic, and there's been a change in who is dying: "The young ones," says Tabvemhiri, "are coming in bulk."

The wide crescent of East and Southern Africa that sweeps down from Mount Kenya and around the Cape of Good Hope is the hardest-hit AIDS region in the world. Here, the virus is cutting down more and more of Africa's most energetic and productive people, adults aged 15 to 49. The slave trade also targeted people in their prime, killing or sending into bondage perhaps 25 million people. But that happened over four centuries. Only 17 years have passed since AIDS was first found in Africa, on the shores of Lake Victoria, yet according to the Joint United Nations Programme on HIV/AIDS (UNAIDS), the virus has already killed more than 11 million sub-Saharan Africans. More than 22 million others are infected.

Only 10 percent of the world's population lives south of the Sahara, but the region is home to two-thirds of the world's HIV-positive people, and it has suffered more than 80 percent of all AIDS deaths.

Last year, the combined wars in Africa killed 200,000 people. AIDS killed 10 times that number. Indeed, more people succumbed to HIV last year than to any other cause of death on this continent, including malaria. And the carnage has only begun.

Unlike ebola or influenza, AIDS is a slow plague, gestating in individuals for five to 10 years before killing them. Across East and Southern Africa, more than 13 percent of adults are infected with HIV, according to UNAIDS. And in three countries, including Zimbabwe, more than a quarter of adults carry the virus. In some districts, the rates are even higher: In one study, a staggering 59 percent of women attending prenatal clinics in rural Beitbridge, Zimbabwe, tested HIV-positive.

Life expectancy in more than a dozen African countries "will soon be 17 years shorter because of AIDS-47 years instead of 64," says Callisto Madavo, the World Bank's vice president for Africa. HIV "is quite literally robbing Africa of a quarter of our lives."

In the West, meanwhile, the HIV death rate has dropped steeply thanks to powerful drug cocktails that keep the disease from progressing. These regimens must be taken for years, probably for life, and they can cost more than $10,000 per patient per year. Yet in many of the hardest-hit African countries, the total per capita health-care budget is less than $10.

Many people-in Africa as well as the West-shrug off this stark disparity, contending that it is also true for other diseases. But it isn't. Drugs for the world's major infectious killers-tuberculosis, malaria, and diarrheal diseases- have been subsidized by the international community for years, as have vaccines for childhood illnesses such as polio and measles. But even at discounted prices, the annual cost of putting every African with HIV on triple combination therapy would exceed $150 billion, so the world is letting a leading infectious killer for which treatment exists mow down millions.

That might be more palatable if there were a Marshall Plan for AIDS prevention to slow the virus's spread. But a recent study by UNAIDS and Harvard shows that in 1997 international donor countries devoted $150 million to AIDS prevention in Africa. That's less than the cost of the movie Wild Wild West.

Meanwhile, the epidemic is seeping into Central and West Africa. More than a tenth of adults in Côte d'Ivoire are infected. Frightening increases have been documented in Yaoundé and Douala, the largest cities in Cameroon. And in Nigeria-the continent's most populous country-past military dictatorships let the AIDS control program wither, even while the prevalence of HIV has climbed to almost one in every 20 adults.

Quite simply, AIDS is on track to dwarf every catastrophe in Africa's recorded history. It is stunting development, threatening the economy, and transforming cultural traditions.

Epidemics are never merely biological. Even as HIV changes African society, it spreads by exploiting current cultural and economic conditions. "The epidemic gets real only in a context," says Elhadj Sy, head of UNAIDS's East and Southern Africa Team. "In Africa, people wake up in the morning and try to survive-but the way they do that often puts them at risk for infection." For example, men migrate to cities in search of jobs; away from their wives and families for months on end, they seek sexual release with women who, bereft of property and job skills, are selling their bodies to feed themselves and their children. Back home, wives who ask their husbands to wear condoms risk being accused of sleeping around; in African cultures, it's usually the man who dictates when and how sex happens.
Challenging such cultural and economic forces requires political will, but most African governments have been shockingly derelict. Lacking leadership, ordinary Africans have been slow to confront the disease. Few companies, for example, have comprehensive AIDS programs. And many families still refuse to acknowledge that HIV is killing their relatives, preferring to say that the person died of TB or some other opportunistic illness. Doctors often collude in this denial. "Just the other day," says a high-ranking Zimbabwean physician who spoke on condition of anonymity, "I wrote AIDS on a death certificate and then crossed it out. I thought, 'I'll just be stigmatizing this person, because no one else puts AIDS as the cause of death, even when that's what it is.' "

Why is AIDS worse in sub-Saharan Africa than anywhere else in the world? Partly because of denial; partly because the virus almost certainly originated here, giving it more time to spread; but largely because Africa was weakened by 500 years of slavery and colonialism. Indeed, historians lay much of the blame on colonialism for Africa's many corrupt and autocratic governments, which hoard resources that could fight the epidemic. Africa, conquered and denigrated, was never allowed to incorporate international innovations on its own terms, as, for example, Japan did.

This colonial legacy poisons more than politics. Some observers attribute the spread of HIV to polygamy, a tradition in many African cultures. But job migration, urbanization, and social dislocation have created a caricature of traditional polygamy. Men have many partners not through marriage but through prostitution or sugar-daddy arrangements that lack the social glue of the old polygamy.

Of course, the worst legacy of whites in Africa is poverty, which fuels the epidemic in countless ways. Having a sexually transmitted disease multiplies the chances of spreading and contracting HIV, but few Africans obtain effective treatment because the clinic is too expensive or too far away. Africa's wealth was either funneled to the West or restricted to white settlers who barred blacks from full participation in the economy. In apartheid South Africa, blacks were either not educated at all or taught only enough to be servants. Now, as the country suffers one of the world's most explosive AIDS epidemics, illiteracy hampers prevention. Indeed, AIDS itself is rendering Africa still more vulnerable to any future catastrophe, continuing history's vicious cycle.

Yet AIDS is not merely a tale of despair. Increasingly, Africans are banding together- usually with meager resources-to care for their sick, raise their orphans, and prevent the virus from claiming more of their loved ones. Their efforts offer hope. For while a crisis of this magnitude can disintegrate society, it can also unify it. "To solve HIV," says Sy, "you must involve yourself: your attitudes and behavior and beliefs. It touches upon the most fundamental social and cultural things-procreation and death."

AIDS is driving a new candor about sex-as well as new efforts to control it, through virginity testing and campaigns that advocate sticking to one partner. And slowly, fitfully, it is also giving women more power. The death toll is scaring women into saying no to sex or insisting on condoms. And as widows proliferate, people are beginning to see the harm in denying them the right to inherit property.

The epidemic is also transforming kinship networks, which have been the heart of most African cultures. Orphans, for example, have always been enfolded into the extended family. But more than 7 million children in sub-Saharan Africa have lost one or both parents, and the virus is also killing their aunts and uncles, depriving them of foster parents and leaving them to live with often feeble grandparents. In response, communities across Africa are volunteering to help orphans through home visits and, incredibly, by sharing the very little they have. Such volunteerism is both a reclaiming of communal traditions and their adaptation into new forms of civil society.

But even heroic efforts can't stop the damage that's already occurred here in the hills where Arthur Chinaka lost his father and uncles. The worst consequence of this epidemic is not the dead, but the living they leave behind.

Rusina Kasongo lives a couple of hills over from Chinaka. Like a lot of elderly rural folk who never went to school, Kasongo can't calculate how old she is, but she can count her losses: Two of her sons, one of her daughters, and all their spouses died of AIDS, and her husband died in an accident. Alone, she is rearing 10 orphaned children.

"Sometimes the children go out and come home very late," says Kasongo, "and I'm afraid they'll end up doing the same thing as Tanyaradzwa." That's the daughter who died of AIDS; she had married twice, the first time in a shotgun wedding. Now, the eldest orphan, 17-year-old Fortunate, already has a child but not a husband.

Few people have conducted more research on AIDS orphans than pediatrician Geoff Foster, who founded the Family AIDS Caring Trust (FACT). It was Foster who documented that more than half of Zimbabwe's orphans are being cared for by grandparents, usually grandmothers who had nursed their own children to the grave. But even this fragile safety net won't be there for many of the next generation of orphans.

"Perhaps one-third of children in Zimbabwe will have lost a father or mother-or both-to AIDS," says Foster. They are more likely to be poor, he explains, more likely to be deprived of education, more likely to be abused or neglected or stigmatized, more likely to be seething with all the needs that make it more likely that a person will have unsafe sex. "But when they get HIV and die, who cares for their children? Nobody, because they're orphans, so by definition their kids have no grandparents. It's just like the virus itself. In the body, HIV gets into the defense system and knocks it out. It does that sociologically, too. It gets into the extended family support system and decimates it."

Foster's chilling realization is dawning on other people who work in fields far removed from HIV. This year, South African crime researcher Martin Schönteich published a paper that begins by noting, "In a decade's time every fourth South African will be aged between 15 and 24. It is at this age group where people's propensity to commit crime is at its highest. At about the same time there will be a boom in South Africa's orphan population as the Aids epidemic takes its toll." While some causes of crime can be curtailed, Schönteich writes, "Other causes, such as large numbers of juveniles in the general population, and a high proportion of children brought up without adequate parental supervision, are beyond the control of the state." His conclusion: "No amount of state spending on the criminal justice system will be able to counter this harsh reality."

More AIDS and more crime are among the most dramatic consequences of the orphan explosion. But Nengomasha Willard sees damage that is harder to measure. Willard teaches 11-and 12-year-olds at Saint George's Primary School, located near the Chinakas and the Kasongos. Fifteen of Willard's 42 pupils have lost one or both of their parents, but he's particularly worried about one of his students who lost his father and then, at his mother's funeral, cried inconsolably. "He doesn't want to participate," says Willard. "He just wants to be alone."

"I see thousands of children sitting in a corner," says Foster. "The impact is internalized-it's depression, being withdrawn." In Africa, says Foster, the focus on poverty eclipses research into psychological issues, but he has published disturbing evidence of abuse-emotional, physical, and sexual. Meanwhile, the orphan ranks keep swelling. "We're talking 10 percent who will have lost both parents, maybe 15 percent. Twenty-five percent who will have lost a mother. What does that do to a society, especially an impoverished society?"

Among his students, Willard has noticed that some of the orphans come to school without shoes or, in Zimbabwe's cold winter, without a sweater. Sometimes their stepfamilies put them last on the list, but often it's because grandmothers can't scrape together enough money.

Among economists, there has been a quiet debate over whether HIV will harm the economy. Some think it won't. With unemployment rates in sub-Saharan Africa between 30 and 70 percent, they reason that there are plenty of people to replenish labor losses. One scenario is that economic growth might slacken, but population growth will also dwindle, so per capita GNP might hold steady or even rise. Then, says Helen Jackson, executive director of the Southern Africa AIDS Information Dissemination Service (SAfAIDS), Africa might face the grotesque irony of "an improvement in some macroeconomic indicators, but the exact opposite at the level of households and human suffering."

But evidence is mounting that the economy will suffer. Between 20 and 30 percent of workers in South Africa's gold mining industry-the mainstay of that country's economy-are estimated to be HIV-positive, and replacing these workers will cut into the industry's productivity. In Kenya, a new government report predicts that per capita income could sink by 10 percent over the next five years. In Côte d'Ivoire, a teacher dies every school day.

Then there are the effects that can't be quantified. "What does AIDS do for the image of Africa?" asks Tony Barnett, a veteran researcher on the economic impact of AIDS. To lure investors, the continent already has to battle underdevelopment and racism, but now, he says, many people will see Africa as "diseased, sexually diseased. It chimes in with so many stereotypes."

Beneath the corporate economy, millions of Africans subsist by cultivating their own small plot of land. When someone in the family comes down with AIDS, the other members have to spend time caring for that person, which means less time cultivating crops. And when death comes, the family loses a crucial worker. Studies have documented that among rural AIDS-stricken families, food production falls, savings dwindle, and children are more likely to be undernourished.

For Kasongo and her 10 orphans, food is a constant problem, but now it has become even harder. On her way back from the fields, carrying a basket of maize on her head, Kasongo tripped and fell. Her knee is swollen, her back is aching, and cultivating the fields is close to impossible. Here, under the radar of macroeconomic indicators, Kasongo's ordeal shows how AIDS is devastating Africa.

This is the context in which one of Africa's most agonizing debates is taking place: Should doctors administer drugs to pregnant women that sharply reduce the chances that a baby will be born with HIV? So far, the debate has centered on the cost of the drugs, but a new, inexpensive regimen has pushed thornier arguments to the surface.

The "vaccine for babies," as it is sometimes called, does not treat the mother and so does nothing to reduce the chances the baby will become an orphan. That's why Uganda's Major Rubaramira Ruranga, a well-known activist who is himself infected with HIV, opposes it. "Many children in our countries die of malnutrition, even with both parents," he argues. "Without parents, it's almost certain they'll die."

Isn't it impossible to know the fate of any given child and presumptuous to decide it in advance? "That's sentimental," he snaps. Even Foster, who believes "every child has a right to be born without HIV," wonders whether the money is best spent on the "technical fix" of giving drugs to the pregnant women. The medicine is only a part of the cost, for women can infect their children during breast feeding, which raises expensive problems such as providing formula and teaching mothers how to use it safely in places where clean water may not exist. Would all that money, Foster wonders, be better spent alleviating the root causes of why women get infected in the first place? "It's very difficult to stand up and make such an argument because you get portrayed as a beast," he says. In fact, such arguments testify to how the epidemic is forcing Africans to grapple with impossible choices.

Weston Tizora is one of thousands of Africans who are trying to give orphans a decent life. Just 25 years old, Tizora started as a gardener at Saint Augustine's Mission and threw himself into volunteering in the mission's AIDS program, called Kubatana, a Shona word meaning "together." Next year he will take over the program's leadership from its founder, British nurse Sarah Hinton. Kubatana's 37 volunteers care for homebound patients, and they help raise orphans by, for example, bringing food to Rusina Kasongo's brood.

Just a few steps from Kasongo live Cloud and Joseph Tineti. They're 14 and 11, respectively, and the oldest person in their home is their 15-year-old brother. They are, in the language of AIDS workers, a child-headed household. Who's in charge? "No one," Joseph answers-and it shows. Their one-room shack is strewn with dirty clothes, unwashed dishes, broken chairs. On the table, a roiling mass of ants feasts on pumpkin seeds and some kind of dried leaves.

The troubles run deeper. Their father, who had divorced their mother before she died, lives in nearby Mutare. Does he bring food? "Yes," says Joseph, "every week." It's not true, Tizora maintains. Kubatana members have even talked with the police in their effort to convince the father to take in his children or at least support them. But the police did not act, explains Tizora, because the father is unemployed and struggling to provide for the family of his second wife. Once a month-sometimes not even that often-he brings small amounts of food, so the orphans depend on donations from Kubatana volunteers.

But if little Joseph's version isn't true, it's what an orphaned kid would want: a father who at least brings food, stops by frequently, and acts a little like a dad. And his mother: What does Joseph remember of her? The question is too much, and he starts crying.

Kubatana volunteers are supposed to look after the Tineti orphans, so why is their home so unkempt? There used to be two volunteers in this area, explains Tizora. One has been reassigned to work in the nearby mining village, ravaged by AIDS. The other has been away at her parents' home for two months, attending to a family funeral and to her own late-stage pregnancy.

And everyone in these villages has their hands full. Standing in a valley, Tizora points to the hillsides around him and says, "There are orphans in that home, and the one over there, and there by the gum trees. And see where there's that white house? They're taking care of orphans there, too." By the time he finishes, he has pointed out about half of the homesteads. When the Kubatana program started, in 1992, volunteers identified 20 orphans. Now they have registered 3000. In many parts of Africa, notes Jackson of SAfAIDS, "It has actually become the norm to have orphaned children in the household rather than the exception."

Foster makes some quick calculations: Given the number of volunteers in the Kubatana program, there's no way they can care for all their orphans. So when a volunteer gets pregnant, has a family emergency, or gets sick, kids like Cloud and Joseph fall through the cracks. Says Foster: "You can't lose a quarter of your adult population in 10 years without catastrophic consequences."

In his office, Tizora has a wall of photographs showing the original 20 orphans. One is a girl who looks about 12. She lost her parents and then she lost the grandma who was caring for her. At that point, she started refusing to go to school, hiding on the way there. Now, she's run away and, Tizora says, "we don't know where she is."


Part 7: South Africa Acts Up
Building a Movement on the Ruins of Apartheid
by Mark Schoofs
December 22 - 28, 1999

Lucky Mazibuko, an HIV-positive columnist, protests U.S. trade policies that allow drug companies to set prices.
photo: Mark Schoofs
Additional articles in this series.

KWAMASHU, SOUTH AFRICA—It's a hot, gray Sunday afternoon in March, and the sprawling Durban train station is almost deserted—hardly the best stage for an AIDS demonstration. Yet sitting on the floor is a small woman named Mercy Makhalemele, one of South Africa's foremost AIDS activists. And she is protesting.

Makhalemele found out she was HIV-positive in 1993. When she told her husband, he shoved her into a pot of water boiling on the stove, scalding her arm. She went to her job selling shoes "as if everything was okay," but her husband showed up telling her to go back home, get her things and leave him, because how could he live with someone infected with HIV? That was at 10:00 in the morning. At 3:00 that afternoon she was fired from her job. Her youngest child, Nkosikhona, meaning "God is there," was born infected. Makhalemele remembers taking her to the hospital and having nurses say, "She is HIV-positive, there is nothing we can do." And Makhalemele would insist, "I'm not asking you to treat her HIV, I'm asking you to treat her bronchitis." Her child died at two and a half.

For most of this time, Makhalemele tried to push her government—the new government of Nelson Mandela, the most progressive in Africa and maybe the world—to fight AIDS.

It looked like it would be easy. Quarraisha Abdool-Karim is one of South Africa's leading HIV researchers, and she was the first to head the country's AIDS control program. She remembers an AIDS conference in 1992, when Mandela gave the keynote. Abdool-Karim was to speak after him, but, she recalls, "there was very little to add. He knew all the issues, everything that had to be done."

But then there was silence. Until the end of 1998, when the prevalence of HIV among South African women attending prenatal clinics surged beyond 20 percent, the only major AIDS speech Mandela gave was to an economic forum in Switzerland. Why he waited so long to confront AIDS remains one of the most maddening enigmas of the epidemic. Mandela declined requests from the Voice for an interview, but even his friend and personal physician, Nthato Motlana, can't plumb it.

"I get so angry," Motlana said in an interview earlier this year. "I go to Mandela—I had breakfast with him this morning—and I give him hell." Exasperated, he adds, "The response by the previous apartheid government was a national disgrace. The response by my government—and I'm a very loyal member of the ANC, have been since the age of 18—has also been disgraceful."

In fact, the new administration made colossal blunders. First, the headstrong health minister, Nkosazana Zuma, authorized a $2.2 million AIDS prevention play, called Serafina II, that hogged a huge portion of the AIDS budget and was widely criticized for being ineffective. Then came Virodene, a locally developed treatment for AIDS. In fact, it contained an industrial solvent, harmful to humans. But Zuma—and Thabo Mbeki, then deputy president and now president of South Africa—championed the drug. When objections were raised by the Medicines Control Council, the South African equivalent of the Food and Drug Administration, Zuma dismissed their concerns, suggesting the council was in league with big pharmaceutical companies that didn't want competition from Virodene.

Finally, in October 1998, the government unveiled its Partnership Against AIDS, a public-private effort that has won high praise for prompting companies, churches, and civic organizations to tackle AIDS. But even as it was being launched, Zuma announced that the government was nixing the so-called "vaccine for babies," a regimen of AZT given to HIV-positive pregnant women that can greatly reduce the chance that babies will be born with HIV. Unaffordable, insisted Zuma, despite a government-funded study showing that giving AZT to pregnant women would save money in the long run, because treating babies with AIDS is very expensive.

Because of her infected daughter, Mak-halemele was especially outraged by the AZT decision. But she was also heartsick about what she saw as the larger issue: "How do we, as people already infected, fit into the government's program? We don't fit in any way because it's all about prevention." So she helped start the Treatment Action Campaign, an AIDS activist group patterned partly on ACT UP but also on South Africa's own tradition of protest politics, a tradition epitomized, of course, by Mandela.

Indeed, Mandela may not have done much for AIDS, but he did give his country a political system that responds to ordinary citizens. In a very real sense, he made AIDS activism possible.

But even Mandela couldn't make it easy. While activists everywhere must push politicians, South African AIDS activists must also cope with a society thrown horribly out of joint by modern Africa's most authoritarian, exploitative white regime. In building an AIDS movement, the legacy of apartheid is the biggest obstacle, even more onerous than errant leaders. Apartheid poisoned people with rage, resentment, and despair, creating a culture of violence and stigma that still haunts people with HIV. That's a problem because, before the infected can band together to fight, they must acknowledge they carry the virus. That's hard everywhere, but in South Africa, people who come out as HIV-positive risk physical assault, even murder.

Makhalemele's home region, KwaZulu-Natal, suffered some of the worst terror, because here a three-way war raged between the white regime, the African National Congress, and the Zulu Inkatha Freedom Party. AIDS activist Musa Njoko grew up in KwaMashu, a forbidding township outside Durban, the kind of place where people seem so beaten down that they are looking for someone weaker to kick. "The boys treated me very roughly," Njoko recalls. "I thought someone would get hurt for being HIV-positive." So she was "shocked but not surprised" when last December a woman named Gugu Dlamini declared that she was HIV-positive and got beaten to death three weeks later because, as some of her assailants were heard to say, her honesty shamed the township.

Three months after Dlamini's murder, the Treatment Action Campaign was kicked off with a nationwide petition drive, and Makhalemele, who had worked with Dlamini, decided to confront AIDS stigma by sending her petitioners to KwaMashu. Wearing T-shirts emblazoned with the photo of the slain activist and the slogan "Never Again," about 20 activists arrived in the township shopping center, a dusty place with bars on all the windows. The activists had requested a police escort, but with no police in sight, they fled.

Makhalemele never made it to KwaMashu. A few days earlier she had asked for the train company to provide the activists free transportation from Durban to KwaMashu. She asked again when she got to the station, and again the answer was no—and something inside her snapped. She sat down in the middle of the station, launching a fast that would last for seven days.

Sitting on the floor of the train station, she starts to weep. "I'm going to a Catholic mission," she says. "I'm going to stay there to heal the sorrow, the pain, the rage I have from working for seven years as an AIDS activist in this country."

Apartheid was never merely a racial system, but also an economic one that created copious wealth. It is possible to travel to Capetown or Johannesburg and believe one is in London or New York. The mansions are palatial. The phones work. The roads are good. All this gives the country a critical mass of educated, prosperous, urban inhabitants—no longer all white—who have a sense that they are entitled to a democratic society that works as well as any nation anywhere. The comparatively strong economy also means that people with HIV can dare to hope for at least some medication to extend their lives.

Of course, South Africa's wealth was created by ruthless exploitation, so the country is also blighted with poverty on a staggering scale. Illiteracy is rampant. Millions lack electricity and running water. This is what people mean when they talk about South Africa as a country of extremes or, as Mbeki puts it, two countries within the same borders. But this does not begin to describe the far-reaching devastation wreaked upon the nation.

To understand apartheid, go not to KwaMashu or even Soweto, but instead descend in a mine-shaft elevator deep below the surface of the Witswatersrand region to the reef, a band of sediment created millions of years ago by prehistoric rains. It's hard to see the gold, but it's there—tons upon tons of it scattered through the reef in mostly microscopic particles. Here is the simple geological fact has shaped modern South Africa more than anything else: Each ton of Witswatersrand earth yields only a few ounces of gold, and the richest deposits lie buried under eons of newer geological layers. So South African mines must plunge deeper than any others—as far down as five kilometers—and miners have to haul up colossal aggregations of earth. Without very cheap labor, it would have been impossible to make a profit.

Yet gold has long been the country's largest revenue producer. For example, the West Driefontein mine in Carletonville has extracted more than 4.5 million pounds of gold. The company has provided splendid housing for the mine manager: a gated mansion complete with manicured garden. The ordinary laborers also live in company housing. Typical is a room about 20 x 20 feet, crammed with 14 bunk beds and lockers no bigger than those in a school gym. The men who live in this room come from across southern Africa, and they are all married. But their wives are back home. The miners see their families only every two or three months, usually for just a few days at a time.

It is a system that was invented nearly a century ago by the diamond and gold industries. Africans were crowded into reservations, where hut taxes forced them into wage labor. Chiefs were paid to supply men—but only men. Housing black families would cost money, and letting black workers settle permanently in mining towns would make it easier for them to organize resistance. So workers were housed in all-male barracks, called hostels, much like the ones at West Driefontein.

Apartheid's mesh of more than 100 interlocking laws basically nationalized the pattern devised by the mining industry, which at its height employed more than a fifth of black South African adults. Apartheid's hated pass laws, which restricted the movement of blacks, grew out of company policies designed to shuttle workers between their homes and the mines. And in the 1960s, the government forced as many as 3 million Africans into barren and degrading reservations they called Bantustans, an Orwellian term intended to prop up the sham that these were independent nations.

Blacks lucky enough to land a job in a city lived in outlying townships—often, in the early days, with their families. But that changed with the infamous 1964 Bantu Laws Amendments Act, which mandated that new workers live in all-male hostels in the townships. The mining model had become national policy, and the results were disastrous.

"I lived next to a hostel in Soweto, and I would get called to treat someone stabbed or shot." Motlana recalls. "The stench in those places! They were filthy. The hostels bred crime, but it goes beyond that. Children were ill-disciplined because they didn't have fathers. It led to so much human abuse."

It also led to an explosion of AIDS. South Africa has one of the world's fastest-growing HIV epidemics, and many researchers believe that the country's system of migrant labor is one of the driving forces. "If you wanted to spread a sexually transmitted disease, you would take thousands of young men away from their families, isolate them in single-sex hostels, and give them easy access to alcohol and commercial sex," says Mark Lurie, a South African researcher who has studied the effect of migrant labor on HIV. "Then, to spread the disease around the country, you'd send them home every once in a while to their wives and girlfriends. And that's basically the system of migrant labor we have."

In Carletonville, Yodwa Mzaidume works with the hundreds of prostitutes that live in squatter camps by the mining hostels. She trains them to educate each other to use condoms, but it's hard to involve them in anything beyond that. "Take Leeupoort," she says, referring to one of the squatter camps. "People there don't have toilets or running water. If you come to them talking about political activism, they ask, 'What's in it for me?' "

In America, the cry of AIDS activists was simple: "Drugs into bodies!" But in South Africa, the needs are so much more complex. Mzaidume ticks off some of them: "Migrant labor, overcrowding, unemployment, the crime rate. But what are we doing about them? What can we do?" Migrant labor, she notes, has become so ingrained into South African life that "mineworkers don't want their families to stay here. They say, 'Who would take care of my cows back home?' "

Mzaidume doesn't dwell on South Africa's past because what's spreading HIV, she quips, "is sex with other people, not sex with apartheid." But with unemployment officially above 30 percent and probably much higher, she says, "There's a lot of anger among the youth. They say, 'Yes, we are in a democratic South Africa, but we still live in apartheid.' "

The result is rage. Njoko, the activist who grew up in KwaMashu, explains: "They'll see me and think, 'She is an HIV-positive woman, how is she doing so well?' And then maybe they'll hurt me or kill me. But when you look deeper you find out the guy has been unemployed for 10 years." Some men even take out their anger by infecting other people, she says, echoing a common conviction. "They say they don't want to die alone, they're going to take people with them. I don't support them, but there's absolutely nothing there for the person who is HIV-positive. The message is they're going to die."

Zackie Achmat is one of the architects of the Treatment Action Campaign. He also fought apartheid, organizing student demonstrations and going to jail for it. Although his ancestry is mixed-race, he called himself black, a tactic of solidarity. He is also a leader of South Africa's flourishing lesbian and gay movement, and with his international connections he could get the very latest medication to treat his HIV. But he has publicly declared that he will not take any drug that is not available to all South Africans.

So when he stood up at a meeting this spring, attended by Zuma, then the minister of health, Achmat had credibility. He told her of his longstanding membership in the ANC, pointed out that the AIDS movement supported her opposition to high pharmaceutical prices, and requested a meeting. To the astonishment of most activists, she agreed. And after the meeting, she reversed her policy on AZT for pregnant women.

It was a stunning victory—and it opened the way for much larger advances, especially on drug prices. It was Zuma who pushed through a law that could allow the South African government to bypass pharmaceutical patents and obtain essential medicines at much lower prices—for example, from companies that make generic versions of the drugs. That made South Africa ground zero in a high-profile battle joined by Western AIDS activists and organizations, such as the Nobel-winning Médecins Sans Frontières, to relax patent and trade restrictions that help keep essential drugs unaffordable. Here was a fight AIDS activists and the South African government shared.

But this fall, President Mbeki shocked activists by saying, "There exists a large volume of scientific literature alleging that, among other things, the toxicity of this drug is such that it is, in fact, a danger to health." Never mind that AZT has been evaluated in dozens of trials around the world, that its benefits usually outweigh its side effects, and that countries as strict as Germany and the United States have approved the drug for use against HIV. Indeed, in a study carried out among pregnant women in South Africa, AZT together with another drug showed no more side effects than a placebo. So where did the most powerful person in Africa get the notion that AZT is dangerous?

From the Web, one of his spokespeople, Tasneem Carrim, told the Johannesburg Sunday Independent. Mbeki's office denied it, but what Carrim said had the ring of guileless truth: "The president goes into the Net all the time," she was quoted as saying. Activists had hoped that Mbeki's new health minister, Manto Tshabalala-Msimang, would correct him, but to their dismay she has staunchly supported him.

In the township near Carletonville, the percentage of 25-year-old women infected with HIV is a shocking 60 percent. Most of these women will probably get pregnant. "Why not give a chance to have a baby that is not HIV-positive?" asks Mzaidume. Then she says, bitterly, "It doesn't matter how many presentations doctors make, if politicians don't want it, it will not be." Mbeki did not respond to requests for an interview by the Voice.

Because there is scant medical evidence to support Mbeki's opposition to AZT, many South Africans are casting about for what might have motivated him. Perhaps years in the struggle against apartheid imbued him with mistrust of powerful white corporations, such as pharmaceutical companies. Maybe, too, it instilled a stubbornness that won't allow him to admit he erred. But since Mbeki's specialty is economics, much of the speculation has gravitated in that direction.

The popular notion that apartheid was overthrown by the ANC is only part of the truth. What also happened is that the apartheid economy collapsed. Treating workers as wholly expendable was fine when industry needed mainly unskilled labor. But as technological advancements demanded educated, stable workers, apartheid's migrant labor system backfired, as did the policy of giving blacks only rudimentary education. "If those stupid fools had just decided to train 100 black engineers a year," says Aggrey Klaaste, publisher of the Sowetan newspaper, "this country would be phenomenal."

But the country was anything but phenomenal when the ANC took power. GDP was actually shrinking. Inflation was running above 15 percent. Capital was fleeing the country. And wasteful spending on police and defense, required to fight an ever bolder black resistance, had burdened the country with a large debt.

Despite being raised by communist parents, Mbeki has charted an aggressively capitalist course. Even though it burdens the economy, he is reassuring international investors by stoically paying off the apartheid-era debt. He has imposed a strict fiscal discipline to accommodate world financial institutions such as the International Monetary Fund. While such policies may boost South Africa in the long run, they have left the government strapped for cash—and AIDS drugs are expensive. "They're terrified of starting down the slippery slope of treatment," says Achmat, "because they think it will cost too much."

That certainly would be true if the government subsidized the costly drug cocktails that have reduced American AIDS deaths. But there is a middle ground. Some of the opportunistic illnesses that kill people with AIDS can be prevented by taking relatively cheap prophylactic drugs. The reason the government isn't providing such drugs is that it isn't being pushed by "a treatment-literate HIV population that knows its rights," says Achmat. "The level of understanding here is vastly different than in Europe and North America." At the start of the Treatment Action Campaign, he recalls, people thought AZT was a political party.

That is beginning to change, largely because activists have pushed the issue into the media. Two powerful unions have thrown their weight behind the Treatment Action Campaign, and science itself is pushing the government. There is a new drug, nevirapine, which seems to prevent mother-to-child transmission as effectively as AZT, and at a much cheaper cost. It's being studied in South Africa, and the results of that trial are scheduled for release at the huge World AIDS Conference to be held next year in Durban. It will become harder and harder for the government not to act.

Already a groundswell is apparent. People with HIV are more and more visible. Makhalemele, for example, is back from her five-month retreat and cohosting Beat It!, a national television show on how to live with HIV. On World AIDS Day this month, she says, the media was "full of AIDS faces." One of them is the Sowetan's Lucky Mazibuko, the country's first openly HIV-positive columnist. He lives in the township and has become a magnet for people who need someone to talk with. Recently he got a letter that shows how attitudes are changing.

"The letter was from an elderly woman saying she had a son who was HIV-positive, but she had rejected him, chucked him out of house. Now, she was working as a domestic for a white family, and her employer's daughter turned out to be HIV-positive. So as part of her job she has to take care of their daughter—and she only saw her son when he was buried."

In a country with at least 3.6 million infected, an old African proverb has new relevance: "Something with horns cannot be hidden." The sick and dead are forcing South Africans to confront the disease, themselves, and their brutal history.

Category: AIDS