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The Hidden Cause of AIDS

1.

In the 1990s, the government of Mozambique first became suspicious, and then suspicion turned to alarm, about rising rates of HIV infection in the southern provinces of the country. Nuns at a Catholic mission hospital in a small railway town in Gaza province had begun noticing that the number of patients coming to them with AIDS was rising sharply. Meanwhile, Ministry of Health surveys were showing that the proportion of adults infected with HIV in Maputo, the capital city, was also rising, from an estimated 1.2 percent in 1992 to nearly 13 percent today. In neighboring Gaza province, the infection rate among adults now stands at around 16 percent.

The HIV infection rate in Gaza is striking, particularly since this is a largely rural area. Most people in southern Mozambique are farmers who live on the land in sultry, timeless villages, where in many respects daily life has changed little in hundreds of years. The small, disorderly plots that provide subsistence to millions of people are the foundation of the economy. Time here is measured by the sun and rain, and during good years, mangoes droop from the trees and the gardens are cluttered with pineapple plants and fat stalks of maize. The men wear battered old suits, and the women wear long colorful wraps printed with pictures of fruits or birds or African presidents. They are, in general, polite and formal people. When friends meet, they engage in long, elaborate greetings, with handshakes, bowing, and curtsying. In Gaza, attendance at Christian churches is quite high, and adultery, though not uncommon, is generally frowned upon.

This drowsy world is not where you would expect a terrible epidemic of HIV, a virus usually associated with truckers and prostitutes, drug abuse and rootless city life. But HIV is now more common in the largely rural Gaza than it is in the capital city Maputo, where there are far more prostitutes and more customers who can afford them. I asked one of the epidemiologists who analyzed Mozambique’s HIV statistics about the situation there. She admitted it was terrible, but it wasn’t so unusual. It was typical of many rural areas throughout southern Africa, including Kwa-Zulu Natal in South Africa, Botswana, and Lesotho, where rates of HIV have soared in the last decade.

What all these regions have in common is that they send large numbers of migrant workers to South Africa. Some of the migrants pick up jobs on plantations and construction sites, and others become involved in prostitution and petty crime. However, the most fortunate migrant workers are miners with jobs on the Witwatersrand gold mines in South Africa. During the past century, the rural provinces of Mozambique, Botswana, South Africa, and Lesotho have sent millions of mine workers to the Witwatersrand. Today, about 300,000 work there, some 40,000 from southern Mozambique alone. The miners sign yearly contracts, and may spend twenty years or more as migrant laborers traveling back and forth between the mines and their rural farms, hundreds of miles away. The migrant labor system in southern Africa has been blamed for many of the region’s ills, including the disruption of family life and rural underdevelopment. Now it is also being blamed for the spread of HIV.1 The long absences from home, the tedious, dangerous work, the drab anomie of life in all-male miners’ hostels, the gangs of prostitutes clinging to the chain link fences around the mines—are all believed to contribute to miners’ higher risk of HIV infection.

The South African Chamber of Mines, which represents such mining companies as Goldfields Ltd. and AngloGold, denies that the migrant labor system has exacerbated the spread of HIV in southern Africa.2 But the findings of the nuns in Mozambique seemed to contradict this. When I visited them last September, they told me that nearly all the male AIDS patients who began turning up at the hospital six years ago had been migrant workers in South Africa. Of those who were migrants, most had been Witwatersrand gold miners. Most people live for five or ten years with HIV before they develop AIDS, so the doctors’ findings provided pretty strong evidence that returning gold miners played an important role in bringing HIV to this region between ten and fifteen years ago.3

In an effort to understand the relationship between gold mining and HIV, I went to South Africa, and visited a gold mine one Saturday afternoon last September. I was brought there by a couple of acquaintances, who were gold miners themselves. We headed for the bar, where a few hundred glassy-eyed African men sat around a courtyard drinking. Some of them were passing around old paint tins containing homebrew, a foaming beverage made from molasses, millet, and other ingredients. The men sat in groups more or less according to nationality—the tall Basotho wrapped in gray blankets, and the South Africans in wool caps and parkas. Deafening African music issued from a pair of loudspeakers, virtually everyone was drunk, and the atmosphere was one of total oblivion. A few men danced by themselves and one fell gracefully over a chair, as if in slow motion, and then lay on the ground.

There were about twenty women in the courtyard; some of them sat joking with the men and others circulated through the crowd in pairs. These bar girls are local prostitutes, who may have sex with twenty different men every week, either in a shack somewhere or in the wooded areas around the mines, under makeshift tents made from plastic bags and twigs.4 The mines now provide condoms to the miners, and the miners say they use them. Or so they told me, although they were so drunk, I seriously wondered whether they were really capable of doing so.

Migrant miners and prostitutes are what the World Bank and other development agencies refer to as “groups with high-risk behavior” with respect to HIV.5 These agencies believe that it is particularly important to encourage members of these groups to use condoms and take other HIV prevention measures, because their risky behavior endangers everyone else. Working with these groups is the foundation of much AIDS prevention work in southern Africa. Mpholo Moema, who works for the Mothusimpilo Project, an AIDS prevention group working in one of the mining towns, explained it to me this way: “This is what we know. This has been shown by the World Health Organization and by USAID [the US Agency for International Development]. You have to target high-transmission groups in your approach to prevent HIV in the community in general.”

And yet evidence from the very same mining region where Mr. Moema works suggests that this does not entirely explain how HIV has been spreading in southern Africa. Recently, a group of South African epidemiologists measured HIV rates among the miners and the prostitutes who solicit in the bushes around the mines. Almost as an afterthought, the researchers also measured rates of HIV infection among ordinary women living in a township about fifteen miles away from the mines. The researchers were not surprised to find that 80 percent of the prostitutes were HIV-positive, or that 30 percent of the miners carried the virus as well.6 But what really surprised them was that nearly 60 percent of the women in the township between the ages of twenty and thirty were HIV-positive. The women in the township were not prostitutes, and they were not particularly promiscuous. Around half said they had had sex with fewer than three different men in their entire lives, hardly high- risk behavior. And yet they were almost as likely to be HIV-positive as the prostitutes were, and they were twice as likely to be HIV-positive as the miners themselves.7

So, am I to understand that the low-risk people are at higher risk than the high-risk people?” I asked a South African nurse who worked with AIDS patients living near the mines.

Yes,” she replied.

We were stunned,” said one of the epidemiologists who conducted the study. It turns out that miners, not surprisingly, prefer long-term girlfriends in the townships to hasty tussles in the wet grass with prostitutes. When they do have sex with prostitutes, they know it’s risky, so they usually use condoms. But they trust their longer-term township girlfriends, who trust them in return, and condoms are used far less often in these relationships.8 The provincial health department is now taking on the difficult task of promoting behavior change and wider condom use in the townships around the mines. However, like much of South Africa’s AIDS program, these efforts are desultory, and began very late.9

2.

I wondered whether HIV was spreading in a similar way in southern Mozambique, where many of the miners came from. I wanted to follow the epidemic back to Mozambique, and speak to rural women from the villages that sent miners to South Africa, and where HIV rates were now very high. I thought they might be able to tell me why the virus had spread so quickly, not just among miners and their wives, but to everyone else as well. Did people use condoms? Were they available? If they didn’t use them, why not?

The best way to find Mozambican women who might be willing to discuss HIV was through local nongovernmental organizations that were helping rural communities cope with AIDS. Certainly there were hospitals in this region, but they could do little to help AIDS patients, except give them relatively inexpensive antibiotics that might postpone their suffering for a while before they died. But AIDS in sub-Saharan Africa is far more than a medical problem. AIDS kills the younger adults who earn the money and grow the food for everyone else, and when these adults become ill or die they leave a terrible vacuum. Indeed, the cost of hospital fees and a funeral for an AIDS victim can be several times the annual income of the average household. Most African countries where AIDS is common have no social welfare system, but throughout the region small organizations other than hospitals and clinics have been doing a great deal to help people cope with the social and economic consequences of the disease. Many of them distribute food and clothing to families left destitute by AIDS illnesses and deaths and care for orphaned children. Some of these organizations also try to prevent discrimination against people with HIV and try to help people who have become impoverished by AIDS deaths to start small businesses. If only I could find such organizations in Mozambique, I thought, they would be able to help me find women to talk to about HIV.

However, finding such organizations in southern Mozambique was not easy.10 Eventually a journalist from one of the local newspapers suggested I contact the Mozambican miners’ union, which is called AMIMO, and speak to its director, Moises Uamusse. I telephoned Mr. Uamusse at his headquarters in Maputo, and he told me he was just about to leave for a town called Xai Xai. Would I like to go with him? I said I would. In that case, could I by any chance give him a lift?

  1. 1

    See, for example, Ruth First, Black Gold: The Mozambican Miner Proletarian and Peasant (St. Martin’s, 1983); and Karen Jochelson, “Sexually Transmitted Diseases in Nineteenth- and Twentieth-Century South Africa,” in Histories of Sexually Transmitted Diseases and HIV/AIDS in Sub-Saharan Africa, edited by Philip W. Setel, Milton Lewis, and Marginez Lyons (Greenwood, 1999).

  2. 2

    Mark Schoofs, “African Gold Giant Finds History Impedes a Fight Against AIDS,” The Wall Street Journal, June 26, 2001, and Dr. M. LaGrange, personal communication.

  3. 3

    Mozambique consists of three regions: southern, central, and northern. However, the central region of Mo-zambique has the most severe epidemic of HIV. Mozambique was at war in the 1980s, and refugees from the central region fled to neighboring countries including Malawi and Zimbabwe, where infection rates were already very high by 1990. According to the health ministry the virus came to the central region with the approximately 1.5 million refugees who returned home in the early 1990s. It is also likely that high HIV rates among Zimbabwean soldiers guarding transport corridors in the central region contributed to high infection rates in the local population. While the HIV situation in the central region of the country became dire almost overnight in the early 1990s, infection rates in the northern and southern regions seemed to be much lower, at least until recently, when infection rates soared in the southern region, but not in the northern region, where rates have remained relatively low.

    HIV could have spread into the southern region from the central region, but this is unlikely, because there is little migration between the central and southern regions of the country. A far more likely possibility is that the epidemic in southern Mozambique spread from South Africa with returning miners and other migrant workers.

  4. 4

    See Catherine Campbell, “Selling Sex in the Time of AIDS: The Psycho-Social Context of Condom Use by Sex Workers on a South African Mine,” Social Science and Medicine, Vol. 50 (2000), pp. 479–494.

  5. 5

    See, for example, “HIV/AIDS at a Glance,” on the World Bank’s Web site (www.worldbank.org).

  6. 6

    The figure for miners may well be an underestimate. Miners are given a physical exam at the beginning of every contract, or about once a year, and those who are too sick to work, including those who might be in the early stages of AIDS, are rejected, and would be excluded from HIV surveys of working miners.

  7. 7

    Denise Gilgen et al., “The Natural History of HIV/AIDS in South Africa: A Biomedical and Social Survey in Carletonville” (Johannesburg: CSIR, 2000).

  8. 8

    Gilgen et al., “The Natural History of HIV/AIDS in South Africa: A Biomedical and Social Survey in Carletonville.”

  9. 9

    See Catherine Campbell and Yodwa Mzaidume, “How Can HIV Be Prevented in South Africa? A Social Perspective,” British Medical Journal, January 26, 2002, pp. 229–232. For articles about South Africa’s terrible AIDS program, and controversies surrounding it, see, for example, Virginia van der Vliet, “AIDS: Losing ‘The New Struggle’?” Daedalus, Vol. 130, No. 1 (Winter 2001), and my article “The Mystery of AIDS in South Africa,” The New York Review, July 20, 2000.

  10. 10

    A recent USAID survey found only two AIDS-prevention groups working in Gaza province, one which markets condoms, and the other an umbrella group that has been trying to mobilize the NGO community by holding workshops and conferences. See David Wilson, Claudia Werman Connor, and the Project Support Group, “An AIDS Assessment of the Maputo Corridor: Ressano Garcia to Chokwe and Vilankulo” (USAID, 2001).

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