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15/12/2001 |
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IT HAS TAKEN until day six in Mozambique for it really to hit home. I�m standing outside Maputo Central Hospital with the hot sun in my eyes and I find I�m angry. I only saw them for a moment in the ward because the paediatrician, Dr Gloria Denga, asked us not to overwhelm them. Armindo (six years old), Elena (two) and Floidi (20 months) are so shrunken that their unblinking eyes seem huge. Before the year is out Floidi and Elena will die of pneumonia, Armindo of TB. Antibiotics do not work, because they require the co-operation of these children�s immune systems, which have never had the chance to develop. How do you feel, I asked Dr Denga, about not being able to help them? She smiles shyly: "Frustration. Impotence." In Europe, a baby born with HIV is put on antiretroviral drugs, then lives at least 15 years, possibly decades. With such a therapy, these three infants in Maputo could do the same: go home, live healthy lives, and go to school. But they have been born in Africa, where the drugs are considered too expensive, and impossible to administer in a crumbling health infrastructure. What moves me most is the solemn dignity of the infants� mothers, Laura, Olga and Mira. The virus in them is still incubating, ticking away, as it is in the bodies of 25 million sub-Saharan Africans. They were infected by being faithful to their husbands who came back from the mines and plantations of South Africa to die of Aids. Now the widows sit, silently and lovingly, looking down at the babies they gave death to. In Africa, the fight against Aids has been entirely based on preventing more Africans from contracting the virus � and it has not worked. "In the history of medicine", Dr Leonardo Palombi tells a group of European journalists in a Maputo hotel, "no epidemic has ever been overcome by prevention alone." Palombi is an immunologist at Rome�s Tor Vergata Hospital and a member of the lay Catholic community of Sant�Egidio. The community has long been involved in Mozambique, where it has 2,000 members and is remembered especially for its role in brokering the 1992 peace agreement which brought to an end the brutal decade-long civil war. Now they are attempting something equally quixotic and prophetic: a nationwide Aids treatment programme, beginning with pregnant mothers. The community began speaking of a strategy which combined both prevention and treatment three years ago. They have spent the past two years training small groups of health workers, who from January will begin administering antiretroviral drugs to about 1,500 pregnant women, whom they expect to prove positive of the 10,000 they test. The drugs will save both the mother and her child. The treatment will also save her other children from becoming orphans. It is a model the community believes can be applied in time to the whole of Africa. The exclusion of Africans from treatment, says the community, is simply due to an absence of will. The price of antiretroviral drugs � currently an astronomic US$1,500 per patient per year � will come down as they begin to be used more broadly, due to economies of scale. And, as a result of a recent change in World Trade Organisation rules, developing countries will soon be able to import much cheaper so-called "generic" drugs. The other objection, that in the context of dirty water and malnutrition the drugs will be ineffective, can also be overcome, so long as people are treated in their homes, and guaranteed basic nutrition and clean water. This is a vast, gorgeous country, a great green empty savannah that rolls into a stunning coastline. With my Italian and Spanish colleagues, I see it unfurl from an old Czech 20-seater twinprop shaking its way north to Pemba. To the west is Chimbuto, a village four hours north of Maputo. There I watched Sant�Egidio members hand over the keys to 34 new concrete houses, built after the floods last year washed away the village�s houses and animals, and drowned many of its people. One by one the 200-odd people of Chimbuto came forward to sign their papers. But for a few elderly men, the village idiot, and clutches of infants, they were all women. After they had sung and danced for joy and gratitude, I had the chance to speak to one of the villagers, Maria Zuleita. Where are the husbands? I asked her. Her Portuguese was limited. "Many dead", she answered, smiling. From the floods? "Many dead in the waters", she replied, "many in South Africa." When do they come back? She made the universal gesture of women who think men useless, and laughed. "The husbands? They just come back to die." Aids kills above all young adults, the most productive sector of the population; it overloads an already crumbling health and education system, and is a time bomb ticking away under the Mozambican economy, which until the floods last year was one of the region�s fastest-growing. The incubation of the virus inside hundreds of thousands of Mozambicans who fled the war to Malawi, Zimbabwe and South Africa � and who came back in the early 1990s infected � is coming to an end. The bomb is going off � silently. Aids in Africa has unique features. Worldwide, the virus � the greatest epidemic in human history after the Black Death, which Aids is set to eclipse in the next generation � is the fourth killer after heart disease and respiratory infections. In Africa it is the first. In the West, Aids is largely confined to "high-risk" groups � promiscuous homosexuals, prostitutes and drug addicts. But in Africa, while these groups are also highly at risk, the virus infects mainly young, heterosexual men and women. The West�s strategy, faithfully implemented by African governments over the past ten years, is to prevent the spread of the virus by urging a message known in South Africa as "ABC": Abstain, Be faithful, or use a Condom. Yet the virus continues to spiral. When Mozambique achieved peace in 1992, prevalence was below five per cent. With peace came freedom of movement: roads were opened, and the rates began to soar. By 1996, eight per cent of Mozambicans had the virus. Today, it is about 15 per cent. Still, the condom remains an effective weapon in the battle, and the Vatican�s continued insistence on a total ban strikes many as perverse. In a continent dying of the virus, to take refuge in a Catholic ideal of condom-less monogamy, rather than influencing the moral choices people actually make, seems, in this context, a deathly withdrawal. Wherever we go, Mozambique is at war, arming its population with little packets of rubber. But in Pemba, a poor, hot, coastal town in the far north of Mozambique, the armoury looks thinly stocked. C�ndido Matias is the efficient local director of the government�s anti-Aids office for the province of Cabo Delegado. He meets us in Pemba�s hospital, the only one for the province�s 1,200,000-strong population. The hospital has a budget of less than US$100,000 a year, and power cuts every few minutes. "We get about 200,000 condoms every three months sent here from Maputo", he tells us. "But the supply isn�t always regular, and the quantities vary." We journalists get out our calculators. Assuming on government figures that 60 per cent of the population is under 24, of whom 11 per cent are sexually active, that adds up to two condoms per person per three months. Angelo Agucheiro is a soft-spoken, serious 20-year-old member of the Sant�Egidio community in Pemba. Community members here visit prisons, feed the homeless, visit the sick or, like Angelo, are involved in Aids work, fostering awareness of the virus among young people. What advice, I asked him, does he give boys of his age? "I tell them that if they sleep around they must use a condom", he tells me straightforwardly. "But I also tell them they must be faithful to their partner, and to embark on a process which leads to marriage." And if they are already having sex, what does he tell them? "They should try to stop." This year, he tells me proudly, he has persuaded three men to give up having sex with their girlfriends until they are married, and in the mean time not to sleep around. "Many others say no, they can�t stop having sex. But many have listened to my advice about remaining faithful. And," he adds, "I think everybody at least listens to the advice about condoms." Impressed by this pragmatic Catholic strategy, I ask him for his view on the government�s prevention campaign. Angelo knits his eyebrows: "I think the campaign has made things worse. People never used to talk about sex, and in that time not many people died of Aids. But now, people talk about it and there is a lot more promiscuity, and a lot more Aids." The campaign, he says, should be about fostering values rather than a premature knowledge. FR LUIS Fernando Lisboa, a Brazilian Passionist missionary working in Pemba, agrees. "It�s unfortunate that the government speaks only about condoms", he tells me that night in the bishop�s residence. "That�s not instilling a change of behaviour." By assuming that relationships are immediately sexual, he adds, the campaign trivialises them. He cites a poster which shows a boy saying to a girl, "I love you". The girl answers, "So will you use a condom?" A change in behaviour, Fr Luis says, is the only way that Africa will ever overcome the virus. Back in Maputo, I put Fr Luis�s objections about the campaign to the Mozambican President, Joaquim Chissano. He is a gentle, affable man with a Lenin beard, the only obvious legacy of his Frelimo party�s communist past. To promote the condom, he argues, is not to promote licence. "I tell young people that it�s like a shield. When you go into a war, just because you�ve got a shield does not mean you should run into the bullets. We avoid the bullets. But the shield is there when the bullet is coming for us, and there is no way of avoiding it. So I say to young people, avoid the bullets but carry the shield in case." Both Church and state seem convinced of the need for Mozambicans to wake up to the reality of Aids, and change their behaviour accordingly. And both know that this cannot happen until Mozambicans quebram o sil�ncio � break the silence over Aids. But when I met Liseta, I realised just how difficult that is to do. I heard her story from Dr Ersilia Buonomo, another of the community�s Roman doctors working in Mozambique. Liseta is an HIV-positive 20-year-old who lives in a poor suburb of Maputo. In September she gave birth to a baby girl, whom she called � with sad irony, as it would turn out � Esperan�a, which means "hope". When Liseta arrived, destitute, at the community�s health centre, four-month-old Esperan�a weighed just 1.2kg. It was too late for Ersilia to save the baby, who died days later, weakened by coughing fits brought on by acute bronchial pneumonia. The community paid for a funeral, and helped Liseta through her grief. Little by little, her story emerged. After her husband had died, presumably of Aids, some months ago, Liseta went with her eldest child, now five years old, to live with her husband�s family. After taking in her son the family rejected her, accusing her of bringing illness to the house, and of infecting her husband. Forced to leave her son, whom she has not seen since, Liseta travelled to Maputo to be with her own family, but they too refused to have her living there. After the death of Esperan�a, her mother let her sleep, for a time, in the house, but did not speak to her. Since September, Liseta has moved from relative to relative, wearing the black headscarf of mourning. She is much better now, but is still unable to admit her condition. When I went to meet her, accompanied by Ersilia and a Sant�Egidio health worker, I found a sweet, tender girl living in a shack with one of her grandmothers. She spoke softly, looking away as I asked her questions. Ersilia has been trying to get Liseta to accept her condition, and has allowed me to make the same attempt. Are you ill now? "Yes." What is your illness? "Asthma." Anything else? "No, nothing else." Her husband, what did he die of? "Malaria." How did your little daughter die? "She was ill. She was coughing, with fever. We went to the hospital in Maputo, and she died." Why was she ill? "I don�t know." Did she have Aids? Liseta lets out a nervous laugh. "No." Do you know what Aids is? "It�s an illness which�I don�t know." Do you know people who have this illness, Aids? "Yes." Do they live around here? "Yes." Do they know they have Aids? "No, they don�t know." If I have Aids, how do you know I have Aids? "Because you�re thin, and you have fever." And Esperan�a, was she not like this? "Yes, but she didn�t have Aids." Liseta began to get agitated, and to speak in her native language. Amelia Alessandra, the health worker, translated into Portuguese. "A baby, when it is born, must be given traditional medicine. Because they didn�t give it to her, she died." So that�s why Esperan�a died? "Yes." A brother of her uncle�s had Aids, Liseta tells me, but the family only found out after he died. Why did he not tell them, Liseta? "Maybe because he was afraid his family would look down on him." And did this happen to you? No, she said, this has never happened. As we leave Liseta, lost in denial, I feel bad about the interrogation. The mind does not erect such barriers without reason. What would it cost her to break them? "She knows there�s no cure", Amelia tells me. "So to admit she has Aids would be like knowing she�s condemned to death. She�s too young to believe that. Almost no one around here who has Aids accepts it. Many of them are women, and they don�t want to think of who is going to look after their children. Without treatment, it�s very difficult to get people to break the silence." Liseta�s story and her level of denial showed me why the prevention strategy has failed. More than the condom, the vital element in any battle against Aids is hope. Without hope, people fall into denial and despair, and so avoid responsibility for preventing the spread of the virus. Without the possibility of treatment, that hope is hard to foster, and breaking the silence over Aids brings in its wake only stigma and rejection. With treatment, of course, people would still die prematurely. But the pattern of denial and death would at last begin to be broken. And, in the mean time, thousands will be able to live a fruitful, healthy existence, snatching from the jaws of impending mortality � as must we all � the love of life itself. Austen Ivereigh is setting up a fund to contribute to the Sant�Egidio Community Aids treatment programme in Mozambique. If you would like to help, please contact him c/o The Tablet, or email ([email protected])
Austen Ivereigh
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