Fascinating NYT AIDS Article

I’m generally not a big fan of most media coverage of AIDS, as it tends to miss what I think are the most valid points: the sociological implications of the disease, while merely promoting fear and panic. Though AIDS is clearly something to be afraid of, invoking irrational fears in people leading to silly arguments such as closing off the borders to Africa, is absurd and doesn’t deal with the issue. Today, the New York Times had a very interesting article that hit on a number of subjects you don’t find too often in AIDS coverage. It’s about a town in Swaziland, which has the highest per-capita AIDS rate in the world: nearly 40% of the country is infected with HIV. As AIDS tends to kill of the healthy and sexually active rather than the weak, young, and old, it shows how very impressive economic gains in Africa have not only been obliterated, but actually reversed due to the death of the work force and parents. I like the way the article notes the prevalence of grandparents and great grandparents in the population, noting that AIDS is not merely a continuation of Africa’s situation. Rather, in the latter half of the century, poverty-stricken countries such as Swaziland had obtained good gains in education and health, reaching life expectancies in the range of 55 to 60, though still short of the rest of the world, impressive gains nonetheless. AIDS was not a continuation, but rather a destroyer. Anyhow, read the article for yourself, if you’re so inclined. I copied it here, as I assume most people are too lazy to register for the NYTimes (even though it’s free) or don’t get it in your home (shame on you!).

Hut by Hut, AIDS Steals Life in a Southern Africa Town

Published: November 28, 2004

AVUMISA, Swaziland - Victim by victim, AIDS is steadily boring through the heart of this small town.

It killed the mayor’s daughter. It has killed a fifth of the 60 employees of the town’s biggest businessman. It has claimed an estimated one in eight teachers, several health workers and 2 of 10 counselors who teach prostitutes about protected sex. One of the 13 municipal workers has died of AIDS. Another is about to. A third is H.I.V.-positive.

By one hut-to-hut survey in 2003, one in four households on the town’s poorer side lost someone to AIDS in the preceding year. One in three had a visibly ill member.

That is just the dead and the dying. There is also the world they leave behind. AIDS has turned one in 10 Lavumisans into an orphan. It has spawned street children, prostitutes and dropouts. It has thrust grandparents and sisters and aunts into the unwanted roles of substitutes for dead fathers and mothers. It has bred destitution, hunger and desperation among the living.

It has the appearance of a biblical cataclysm, a thousand-year flood of misery and death. In fact, it is all too ordinary. Tiny Lavumisa, population 2,000, is the template for a demographic plunge taking place in every corner of southern Africa.

Across the region, AIDS has reduced life expectancy to levels not seen since the 1800’s. In six sub-Saharan nations, the United Nations estimates, the average child born today will not live to 40.

Here in Swaziland, a kingdom about the size of New Jersey with one million people tucked into South Africa’s northeast corner, two in five adults are infected with H.I.V., the virus that causes AIDS. Life expectancy now averages 34.4 years, the fourth lowest on earth. Fifteen years ago, it stood at 55. By 2010, experts predict, it will be 30.

Epidemics typically single out the aged and young - the weak, not those at society’s core. So what happens to a society when its fulcrum - its mothers and fathers, teachers, nurses, farm workers, bookkeepers, cooks, clerks - die in their prime?

Part of the answer lies in Lavumisa, where two visitors spent five weeks recently talking to more than 60 residents, following the terrible ripples that an unrestrained epidemic is sending through the community. Sickness leads to death, death leads to destitution, destitution worsens a host of social ills, from illiteracy to prostitution to abandoned babies. Multiply a single illness or death scores of times, and a town like Lavumisa begins to unravel.

The average life expectancy here is 34 years, but there are fewer and fewer 34-year-olds - just the very young and the old, struggling to do a 34-year-old’s job.

Today, Lavumisa’s schools are collapsing. Crime is climbing. Medical clinics are jammed. Family assets are sold to fend off hunger. The sick are dying, sometimes alone, because they are too many, and the caretakers are too few.

Much of this is occurring because adults whose labors once fed children and paid school fees and sustained families are dead. Lavumisa’s lost generation of adults has reached beyond the grave, robbing survivors of their aspirations, reducing promising lives to struggles for existence.

Sixteen-year-old Nkuthula Madlopha wanted to be a police officer. Instead, next year she will till her grandparents’ fields, filling in for her dead parents. Her brother will herd livestock.

Their grandmother, Vayillina Madlopha, wanted a quiet old age. Instead, at 80, she is a new mother. “I thought my daughters-in-law would be serving me food, washing for me and cleaning the yard,” she said. “Now I must start afresh.”

Eleven-year-old Ntokozo wanted to be a third grader. Instead, he lies on the floor of his one-room hut, his knees swollen like baseballs and his mouth pitted with sores. His mother, who died in May, infected him with H.I.V., either during her pregnancy or later as he helped tend her oozing sores. His sister, Nkululeko Masimula, 26, wanted a job. " I wanted to have my own business; to be a hairdresser or a wholesaler," she said. Instead, she tends her brother and their 61-year-old grandmother. She sells the family’s chickens to raise money for food. Finding the $20 a month required to take her brother to the nearest antiretroviral drug site, 60 miles away, is a pipe dream.

Dido Khosa, 9, wants his mother back. “She used to cook food, wash my clothes, do things for me,” he said, sobbing. Instead, he describes a life of regular beatings by his father and his father’s girlfriend and periodic escapes to the homes of neighbors.

Delisile Nyandeli, slim and pretty, wanted her own home and family. Instead, she cares not only for her orphaned sisters and brothers, but also for the orphaned children of two sisters who died of AIDS and whose husbands fled. At age 20, she is a mother to nine other children besides her own boy.

“Today, when I was cleaning this house,” she said, "I thought about it - if my mother were alive, she would be the one doing this. Because when my sisters don’t have any pencils or other things they need for school, they come to me.

“And I can’t help them.”

A Hard Life Made Harder

Baked by drought, blessed with a single paved street, a gas station, two liquor stores, two bars and a wretched crafts stand for tourists speeding from the adjacent South Africa border post, Lavumisa clings to Swaziland’s lower rungs. Life would be hard here, even without AIDS.

A mostly rainless decade has discouraged most farmers from planting maize, the staple crop, much less the cotton that once underpinned the local economy. Many survive on homegrown chickens and pigs, donations from the World Food Program and the kindness of relatives who work across the border or in Swaziland’s better-off cities.

The town does not keep death statistics. Most people quietly bury relatives in their yards or nearby fields rather than buy a cemetery plot. But Mzweleni Dlamini, the acting chief for Lavumisa and the surrounding region, does not need a tally to tell him the toll is very high.

Two years ago, he shifted his regular meeting with subordinates from weekends to Tuesdays because Saturdays and Sundays were consumed by funerals. Now he has given permission for weekday funerals because there are too many dead for the traditional weekend services alone.

With the dead gone, it is the impoverished survivors’ turn to suffer.

At Lavumisa Primary School, a beige L-shaped building of concrete classrooms clumped around a red dirt yard, enrollment has fallen nearly 9 percent in five years, to 494 students, as children drop out to support families. One in three students has lost at least one parent.

Nomfundo, a 15-year-old seventh grader, made the four-mile trek home from school one recent day with her brother, Ndabendele, 10. He carried his books in a torn plastic bag. She sported the shaved head customary for girls in mourning.

Their 34-year-old mother, a domestic worker, died Aug. 29; their father died in 2003. Care of the children has fallen to their grandmother, Esther Simelane, 53, who has been jobless for 14 years.

Since the illnesses began, she has sold four of the family’s eight goats to raise money for food.

“Wheesh! Now I can feel the hardship,” Nomfundo said. “Who is going to pay my school fees? Even the clothes. Where am I going to get them?” She tugged at her school uniform skirt, riddled with holes and hemmed several times to hide tears.

“I feel small,” she said. "We used to have track suits. Now we no longer have track suits. Other kids say, ‘Oh, now you don’t have a track suit. Not even shoes! Now you are on the same level as us.’ "

Actually, the two children are headed lower. Unbeknownst to them, their grandmother has tested positive for H.I.V., apparently contracting the virus while dressing her daughter’s bleeding sores. Mrs. Simelane has kept the news from Nomfundo and her brother to spare them further trauma.

Should Nomfundo manage to stay in school another year, she will move up to Ndabazezwe High School. Elphas Z. Shiba, the headmaster, keeps careful track of his 366 students in stacks of ledgers.

Mr. Shiba can state that at the beginning of this year, Ndabazezwe High had 40 students who had lost at least one parent. Nine months later, there were 73, 20 of whom had lost both father and mother, nearly all of whom are desperately poor. A decade ago, Mr. Shiba said, the school had perhaps five orphans, none of them needy.

Both the primary and the high school are staggering under the burden of feeding and educating a growing army of orphans who, by and large, cannot pay the school fees. The state has pledged to pay to educate orphans, but so far it has picked up but half the Lavumisa primary-school fees. Mr. Shiba said the high school was getting a mere $15 of the $100 a year it costs to educate each orphan.

Ndabazezwe High School is now deeply in debt by Swazi standards. It owes $275 for electricity; $200 for water; $260 for books and hundreds more for office equipment. The security guards have not been paid in two months. Borrowed money bought the woodworking and home-economics materials needed for final exams. Even school lunches are hit-or-miss.

Mr. Shiba and Stephen Nxumalo, the headmaster at Lavumisa Primary, reluctantly intend to carry out a resolution adopted in May by the nation’s main teachers’ organization. Starting in January, students who do not pay their fees - currently about 100 in the primary school, 258 in the high school - will be barred from classes.

“The number of those who don’t pay keeps increasing,” Mr. Nxumalo said. “It’s because of the orphans. We are going to send them home, because we have no option.”

Tibuthye, Sandile and Nkuthula Madlopha stand to be among the first to go.

Their parents are buried on a hillside outside Lavumisa. Their father died in 1999 at 46; their mother three years later at 32. The father’s parents, 80-year-old Vayillina Madlopha and her 82-year-old husband, Ellias, now raise three children, ages 10, 12 and 16, on Ellias’s $75-a-month pension.

For the old couple, the son’s death was a double blow. Gone is the $30 a month that he gave them to supplement their meager income. Gone is the extra labor and money for diesel fuel that he provided during the planting season on their farm. Their fields of maize, pumpkin and beans now lie fallow.

After school one day, Mrs. Madlopha bent over an open fire, teaching 10-year-old Tibuthye how to bake buns to sell at school for a few cents. “I am old, I will die,” she said. “They must learn how to work, so they will be able to do these things on their own.”

Nkuthula, 16, has plans for after her graduation. “I want to be a police,” she said in halting English. But the Madlophas cannot afford to fix their broken tractor, much less to educate three children.

“They need too many exercise books and school uniforms,” Mrs. Madlopha said. “We can’t afford all that. We are failing them.”

Grim Choices for Children

What has befallen the Madlophas is happening across Lavumisa. When a family loses a parent to AIDS, public health experts here say, the household production of maize quickly falls by half; the number of livestock owned by nearly a third. It is the equivalent of draining the bank account.

Unable to both feed and educate their children, impoverished single parents frequently farm them out to relatives, following an axiom of Swazi culture that one takes care of one’s own blood, no matter the cost. One in six families has already has taken in a child left parentless by AIDS, according to the World Food Program.

“We Swazis don’t believe there are orphans,” said Lavumisa’s mayor, Victor Simelane, who is not related to Esther. “But now the extended families cannot support the magnitude of the orphans.”

Increasingly, such children face a grim choice: either seek shelter with whomever will take them in, or live on the streets.

As he walked down Lavumisa’s main drag, yards from the South African border gate one afternoon last month, the mayor spotted Thabiso Mavimbela, 12, darting across the macadam. “You see,” he said, “here is one of these street kids. They don’t have extended families. They’re loitering around the town.” Five years ago, he said, such kids did not exist.

Thabiso’s world is a fearful place. He spends much of his after-school time on Lavumisa’s streets. After his mother died five years ago, his father abandoned him. He ended up in his great-grandmother’s mud-and-stone hut, , its walls a checkerboard of holes and openings stuffed with rags, down a rutted dirt road from the primary school.

The two sleep on grass mats on the dirt floor. Thabiso’s uncle occupies the only foam mattress. Thabiso has no toothbrush, no washcloth, nothing except his tattered clothes. At night, he said, mice bite his feet.

Those are the least of his problems. "My uncle tells me: ‘When your great-grandmother dies, I will kill you too,’ " he said. Panicky, he grinds his wet eyes into the cuff of his green-and-yellow school uniform. “I know that when she dies, I have to be killed. I don’t have any other place to go.”

Thabiso’s uncle says the boy is treated well. But in an interview in early September, his aunt, Thembi Simelane, said Thabiso sometimes sought refuge in her home, declaring that he would rather sleep on his mother’s grave than in a hut with his uncle.

Ms. Simelane once was Thabiso’s lifeline. Despite losing her husband to AIDS three years ago and rearing her own five children, she supported the child with profits from clothes bought in South Africa and resold in Lavumisa. But she had to abandon that work last year when she, too, fell ill.

Last January, she tested positive for H.I.V. “My days are numbered,” she told a visitor in September.

She showed a speechless Thobile Jele, a social worker at the mayor’s office, a will scrawled in black crayon on school notebook paper. It bequeathed to Ms. Jele her five children. It did not mention Thabiso.

At the end of October, Ms. Simelane died.

Roaming Lavumisa’s streets with Thabiso is Dido Khosa, 9, whose mother died in 2002 at age 28. His father and his new girlfriend now care for him, after a fashion.

When a neighbor questioned him some weeks ago, Dido told her he had spent two days alone at home without food.

Filching family money to buy bread, he said, brings a stiff penalty. Pulling down his dirty sweat pants, Dido displayed a two-inch scar on his thigh where, he said, his father had beaten him with a pipe. He worried an abscessed tooth with a stick.

“I eat when there is food at school,” he said.

Asked who takes care of him, he replied, “No one.”

In August, Lavumisans noted a new sign of the growing stress on families: two abandoned babies, left on doorsteps days apart.

A Weakened Work Force

In a way, one might not expect the hollowing out of Lavumisa’s adult population to have much affected its minuscule economy. Unemployment in Swaziland averages 34 percent. There is no shortage of cheap labor to replace a fallen clerk or farm worker.

But the death rate is transforming businesses and the work force, in ways not easily visible.

Peter McIntyre, 66, is one of Lavumisa’s real estate baron’s and probably its biggest private employer, owner of a grocery store, a liquor store, the gas station and the Lavumisa Hotel. He has lost about a fifth of his 60 workers to AIDS; the latest, a yard worker named Julius, died Oct. 4. Another worker is dying, he said; she begs him daily to look after her five children when she is gone.

Employees like the yard worker are easily replaced. Not so his accountant, who died of AIDS in 2001. Mr. McIntyre’s relatives said it took three months to find and train a qualified replacement.

His three sons, in their 30’s and heirs to the empire, see a lesson in that. The South African government intends to buy the land beneath the grocery and hotel and build a new border crossing. The sons are not sure that they want to rebuild after the sale.

“My sons are very wary to open a new shop,” Mr. McIntyre said. “They say you have so many hassles - people dying; you can’t build a permanent staff. I don’t know where it is going to end, what’s going to happen to Swaziland.”

Medical clinics are caught in a double squeeze, with mushrooming caseloads and a steadily sicker staff. Visits to Lavumisa’s one-room medical clinic have jumped by nearly a fifth since 2000. At the regional health center in nearby Matsanjeni, home to the only doctor within at least 30 miles, outpatient visits have tripled since 1998.

The Matsanjeni clinic is chronically short-staffed. On an average day, officials say, at least one of its 18 nurses is either sick or on leave for a funeral. The administrator suspects that the recent deaths of at least two clinic workers were caused by AIDS. Mothers-to-be suffer most; the prenatal clinic is closed much of the time.

Only one segment of the economy is prospering. In the Lavumisa region, with 21,000 residents, reported crimes over a three-month period - largely burglaries, assaults and thefts of goats or cows - have increased 25 percent in two years.

Prostitution is booming. On the broad dirt road that parallels the South Africa border sit the Lavumisa Hotel, the town’s two bars and, each evening, a string of 18-wheelers parked for the night. More than 1,100 rigs cross this border every month, fueling a growing sex trade with local women.

In 2000, a report for the United States Agency for International Development concluded that Lavumisa had five resident sex workers. On a recent Thursday night, perhaps a dozen worked the bars.

Some are recent AIDS orphans. They are driven by their poverty: performing sex with a condom nets a woman about $4.50; without a condom, perhaps $9. An enterprising sex worker can make $50 a night.

“I used to stay with my mother and father, before they died of H.I.V. illness,” said Thebisa, 18, during a break at the Lavumisa Hotel bar. “And then I couldn’t afford to go to school. My father died in '98. The following year, it was my mother. I began working this way in 2000.”

Her 19-year-old friend, Dabsile, another AIDS orphan, said: “A lot of my friends are in this business. Some of us, it’s because there’s nobody to look after us. For some of us, it’s because there’s peer pressure.”

Dabsile said she was terrified of getting AIDS, and in fact, AIDS warnings are plastered on storefronts and billboards in Lavumisa. Jars of free condoms sit on the border-crossing counters and on other counters across town. Counselors advise prostitutes and truckers alike about protected sex.

Yet Dabsile has never worried enough to take an H.I.V. test or to insist on condoms with her boyfriend, who knew nothing of her truck-stop trade. They initially had protected sex, she said, “but as time goes on, you don’t as much.”

A Gathering Storm

Lavumisa and other towns like it are windows into the crisis that has beset Swaziland. AIDS kills an estimated 50 people here and H.I.V. infects 55 more each day, erasing hard-won economic gains of the last 20 years, according to the United Nations and the World Health Organization.

“It is the most efficient impoverishing agent you can find; it just sucks out the resources,” said Dr. Derek von Wissell, who directs Swaziland’s National Emergency Response Council on H.I.V./AIDS, the agency charged with stemming the epidemic.

Until the late 1990’s, when AIDS began to hit with force, Swaziland seemed a society on its way up, making strides in health care, education and income. No more.

Economic growth and agricultural production have slowed. School enrollment is down. Poverty, malnutrition and infant mortality are up. By 2010, the United Nations forecasts, children who have lost one parent or both will account for up to 15 percent of Swaziland’s one million people.

The adult H.I.V. infection rate, 38.8 percent, now tops Botswana’s as the world’s highest. The death rate has doubled in just seven years.

“Swaziland is frankly beyond the threshold of what we thought could happen,” said Duncan Earle of the Global Fund to Fight AIDS, Tuberculosis and Malaria, who oversees $48 million in AIDS-related grants to the kingdom. “Ten years ago, we thought the peak infection rate would be 20 to 25 percent. This stretches the imagination.”

A long-promised flood of antiretroviral drugs financed by the Global Fund and other donors could help stem the carnage. But like the rest of sub-Saharan Africa, Swaziland is starting slowly. Only about 4,000 of the 26,000 who need drugs get them. Perhaps 8,000 will have them by the end of 2005.

In 16 months, the Global Fund has disbursed $5.1 million in AIDS grants to Swaziland. Yet not until this month did the overwhelmed Health Ministry hire its first two doctors to work on H.I.V. programs. Some $2.8 million earmarked for orphans’ education is locked in the Treasury, even as the government this year spent $600,000 on the king’s 36th birthday party.

To the United Nations envoy for AIDS in Africa, Stephen Lewis, it is hard to fathom the consequences awaiting a nation with a vanishing middle generation.

“I resist an apocalyptic scenario,” Mr. Lewis said. "But I have to admit, in the middle of the night I ask myself: ‘How are these societies going to survive?’ "

Lavumisa’s story is not entirely bleak. Two decades into the epidemic, Mayor Simelane said, people here are “beginning to accept that they are being attacked by this monster” instead of linking AIDS to witchcraft or a white plot against blacks.

The city allots 2 percent of its limited budget to anti-AIDS social work, and has a $2,000 emergency fund for burying the dead. Chief Dlamini, King Mswati III’s representative to the area, has dedicated three acres to a garden for orphans. A free feeding center for orphans is under construction near the town butchery. The high school has started a garden to feed hungry students.

A new mobile H.I.V. testing center is drawing customers on its weekly visits. One recent afternoon, two dozen people, mostly women, waited for it to open. At the Matsanjeni regional health center, seven miles away, a counselor said 350 to 400 people had visited since testing began last December.

But for every resident who faces AIDS or steels himself for a test, another shies away, fearful of the outcome.

Busisiwe Matse, a 44-year-old mother of six, went to the center in early October. Her husband, Boy, a former miner, is bedridden with symptoms of AIDS. She had been almost constantly ill for nearly a year. She was almost relieved, she said, when the counselor informed her that she was infected because now she can seek treatment.

Boy Matse’s other wife, Khanyisile, 27, refuses to check her own status. “I’ll do it later,” she said.

Dr. von Wissell, the Swazi AIDS czar, has an ambitious agenda to reach families like the Matses. He plans to use Global Fundmoney to speed drugs, food and social support to towns hits by AIDS and to increase care for orphans.

Despite a sluggish start, he said, the government is moving as quickly as the frail health infrastructure permits. Antiretroviral treatment could be available near Lavumisa in six months, he said, but that will not be enough to halt the epidemic.

He does not know, he acknowledged, how much worse that epidemic will become.

Virtually all the Swazis dying today were infected in the 1990’s, when the infection rate was far lower than it is today. Those who are just now infected will not fall gravely ill until about 2012 - a tidal wave of illness and death that is still eight years away.

How Lavumisa and other similar towns will cope with that is anyone’s guess. “Nobody has ever walked that road,” Dr. von Wissell said. “Nobody.”

I’m at a loss as to what can be done to salvage a country in that state. Fuck.

It’s amazing, but not surprising, that a country with such an affliction would note such a large increase in prostitution. Not surprising, because prostitution often seems the best option for poor, orphaned, or otherwise socially downtrodden girls (and sometimes boys), but amazing that there is so little knowledge of the disease that people would continue going to prostitutes in a country where almost 40% of the population contains the virus. When you consider that fact alone, I agree, I have no idea what can be done.