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The Hidden Cause of AIDS

The following morning, Mr. Uamusse took me to a small clearing beside the main road, where a table and chairs had been set up under a tree. About thirty people were waiting for us, mainly miners and former miners and the widows of miners. Mr. Uamusse made a speech in Portuguese, and then, with him as interpreter, I interviewed some of the women in the group one by one. I wanted them to tell me how their community had been affected by HIV, what they thought they needed to confront the epidemic, and how they felt about condoms. But I soon realized these women did not want to discuss HIV at all. Although people in southern Mozambique are facing a terrible plague, what they wanted to talk about instead was money.

The women spoke softly, and when the wind blew through the trees you could hardly hear them. An old woman said her mine worker husband had died in an ambush during the war in 1990. She believed that he had contributed to some sort of pension fund, and she had been trying to collect this pension for the past eleven years. She went to the office that deals with mine workers’ pensions every few months to see if there was any money for her, but each time she was told that the money had not yet arrived. Sometimes she was told to go home and return with some document or other—perhaps a birth certificate, or a death record—but when she returned, the answer was always the same. “You come back later,” they said.

The other women had similar tales. They all carried paper envelopes or plastic bags full of documents: birth certificates, death certificates, employment records, bank books, old bus tickets, receipts for things bought in South Africa—a stereo, a refrigerator, a mattress, some shoes. From what the women told me, it sounded as though some of their husbands might have died of AIDS—they had lost weight before they died, or had had tuberculosis that couldn’t be cured. But the women all said they didn’t know what their husbands had died of, and on the death certificates it was written that the cause of death was “undetermined.” When I mentioned AIDS, the women said they had heard of it, but they knew nothing about it and looked away.

More people kept showing up while I was talking to the widows, and before long there were about fifty people in the clearing waiting to speak to me. I asked Mr. Uamusse whether any of them would be willing to discuss HIV, but when Mr. Uamusse addressed my question to the crowd in the clearing, everyone quietly left.

Where are the AIDS widows and the sewing machines you told me about?” I asked Mr. Uamusse when we were alone again. The statistics from the health ministry and the women’s own stories convinced me that AIDS was a serious problem in Xai Xai, but the people who lived here clearly had other ideas about what their problems were. This is what they had come to tell me, but I did not understand them at first. Mr. Uamusse would say only this: “From our speeches, you will hear things that are true, and things that are not true. It is up to you to find out what is true.”

While I pondered these mysterious words, a teenage boy approached us. He was wearing blue jeans, which gave him a more modern appearance than the other men, in their battered jackets and trousers. He told Mr. Uamusse he wanted us to meet his mother, and we followed him down a sandy lane to a small plot of land with a single concrete building on it, and a few shady papaya trees. Three little girls scampered in the yard and an old woman with bare feet as tough as car tires dozed under a tree. A younger woman, who was the boy’s mother, lay on a straw mat in the yard. Her name was Elisa, and she was very thin and coughed a lot and was clearly dying of what looked to me very much like AIDS. She said she had been sick for more than a year, but she found out only a month ago what the sickness was. “It is TB,” she said. But if this were a case of simple TB, the hospital in Xai Xai, which is equipped to deal with it, would not have waited a year to give her a diagnosis.17 Her husband had worked in the South African mines for nearly twenty years until 1999, when he was sent home for medical reasons. I asked her what the doctors had told him about his illness, but she only said the doctors “did not discover the sickness. They only said he got it in South Africa.” What did he look like before he died? “He got so thin,” her son said. “Everyday he seemed to get thinner and thinner. He died two weeks after he got back.” What do you think it was? “Maybe,” he said, “it was the century sickness,” which I would learn was a local euphemism for AIDS.

Like the other women, Elisa knew that her husband had put some money in a pension fund in South Africa. Shortly after he died in July 2000, she went to the local mine workers’ pension office to collect it, but was told that if she wanted the money, she would have to go to South Africa to get it in person. So she applied for a South African visa, and prepared to set off. But then she herself became ill, and feared she might not survive the eight-hour bus ride. She returned to the pension office, to ask whether she could send one of her children in her place, but was told this would not be possible. And there the matter stood, while she waited to recover. But she never did. In the meantime, the family was finding it increasingly difficult to make ends meet. One by one her children were being forced to drop out of school, but they could not find steady jobs. Her mother-in-law, the old woman under the tree, earned some money for the family by laboring on a nearby farm, but she was paid less than a dollar for a ten-hour day. By now, more than a year had passed, and Elisa’s only hope was that pension. “Many women around here are crying [because of poverty],” she said. Indeed, one of the other widows told me she was worried that if she didn’t get her pension money, her daughters would fall into prostitution.18

3.

Last year, the US Agency for International Development funded an investigation into the AIDS crisis in southern Mozambique.19 The researchers started in the usual way, by searching for groups with higher-risk behavior, meaning prostitutes and the people whom they serve, such as truck drivers and migrants. But the researchers were able to identify relatively few real prostitutes in this region. They did discover, however, that many other women—farmers, market traders, housewives, and so on—form steady, sometimes clandestine, relationships with relatively wealthy men in the hope that it will bring them some material benefit, the occasional chicken perhaps, school fees for the children, or favorable deals for a few cabbages.

These people are so poor, in other words, that sex has become part of their economy. In some cases, it’s practically the only currency they have. A Mozambican doctor I met in Gaza explained it to me this way: “The railway line that goes through this town links Mozambique with South Africa and Zimbabwe. During the war in the 1980s, the trains were guarded by soldiers from those countries. There were shortages of food in those days and the relief supplies would come into Mozambique on those trains. Many of the women around here were starving, and they would sell their bodies just to eat. The problems started then.”

AIDS has been described as a disease of inequality, which settles along the ever-deepening chasm between rich and poor.20 In southern Mozambique, returning miners with relatively high wages paid in the formal economy meet the staggering poverty of rural women struggling to make a living in the “informal” economy. The collision between these two worlds may disrupt the social ecology of those impoverished villages, the way a new, aggressive species disrupts a forest or a lake, creating favorable conditions for the spread of HIV. The rural areas that send miners to the Witwatersrand are riddled with HIV not merely because the miners are migrants, but because the miners bring money home with them. The poor themselves seem to know that money is at the root of their AIDS problem. Perhaps this is why, when I came to talk to them about HIV, they told me about money instead.

A few days before I met Elisa, I had visited the central office that deals with Mozambican mine workers’ pensions in Maputo. The institution is called TEBA, which stands for The Employment Bureau of Africa, and it was established in 1902, as the recruiting arm of the South African Chamber of Mines. It is still associated with the chamber, and is paid by the mining companies to recruit mine workers and disburse their salaries, pensions, and benefits. The director, an amiable white South African, explained the various pension and benefit funds that mine workers contribute to, and the many routes, through banks and ministries, that the money takes before it reaches his office, and then the beneficiaries.

On the way out, I passed through the section of the TEBA office where financial transactions take place. Some thirty women sat on benches in the waiting area, most of them in bright kerchiefs and long skirts like Elisa and the other farm women in Xai Xai. A few clerks sat behind a transparent partition, surrounded by listing heaps of dusty paper. The clerks silently examined documents or filled out forms, and they moved so slowly, it seemed as though time in the TEBA office had nearly ground to a halt. The women in the waiting room were so quiet and still, and seemed so patient, as though they had been painted there. During the months after I left Mozambique, Mr. Uamusse and I contacted the TEBA office several times on Elisa’s behalf, and also on behalf of another AIDS widow I met, and we were always reassured that the cases would be resolved very soon.21

How many widows are in the same position as Elisa? Recently, TEBA officials admitted that pensions and compensation money are owed to at least 10,000 Mozambican miners who lost their jobs during the past twenty years, or to their families, if the men have died. But, the officials claim, they have not been able to find the beneficiaries, because of population movements caused by the war that ended ten years ago.22 Why, in that case, was I was able to meet at least fifty potential claimants during a single weekend?

It is not known how much money is owed to the peasants of southern Africa by mining firms, insurance companies, government bureaucracies, pension funds, and other institutions, but it didn’t take much effort for me to discover that about $40 million of unclaimed money has accumulated in the major pension fund to which most black, unskilled miners contribute, and that about $2 billion is owed to hundreds of thousands of former mine workers who developed silicosis disease from dust exposure in the mines and are therefore eligible for compensation, but almost none of them have been paid either.23

The World Bank itself admits that the inefficiency and corruption of the basic institutions that should serve the poor, including banks, pension funds, insurance companies, courts, and real estate transfer systems, are a major hindrance to economic development throughout the third world.24 Making these institutions work requires government oversight, and so does rebuilding Africa’s devastated economies. But donor policies emphasizing free trade and small government make regulation of such institutions more difficult.

Peter Lamptey of Family Health International, an agency that implements AIDS programs for the US Agency of International Development, has written that such programs shoud include awareness-raising to encourage people to use condoms and have fewer sexual partners, and improved treatment services for other sexually transmitted diseases that make HIV transmission more likely. He also argues that the social conditions that make people vulnerable to HIV infection in the first place must be improved, including poverty, unemployment, and discrimination against women.25 These recommendations have been in place for years, but even Dr. Lamptey admits that they have not been as successful as he originally hoped they would be. The reasons why behavior change in response to HIV has been so slow in many developing countries are complex and largely still mysterious. However, it is possible that by emphasizing HIV prevention among “groups with high-risk behavior,” such as truckers and migrant workers and prostitutes, some development agencies recognized too late the risks faced by others. It is also possible that people in communities that have been broken by war and migrancy, and by continuing economic hardship, will be slow to take HIV awareness messages seriously. It is also possible that improving the social conditions that make the poor vulnerable to HIV is difficult when their fate is sometimes in the hands of remote economists and corrupt officials and businessmen.

Mozambique was once a colony of Portugal, but was heavily influenced by its commercial relationships with neighboring British administrations in South Africa and Rhodesia. I sensed there was some cultural influence from these neighbors as well.26 When I was in Mozambique, I couldn’t escape the impression that there was something Victorian about the place—the women’s long skirts, the hypocrisy about sexual matters, the absurd bureaucracy, the impoverished masses, and the misdirected charity that fails to help them. Along with the migrant labor system, all these may also help explain why HIV is so common in this part of the world.27

  1. 17

    In 2001 it was common for Mozambican doctors not to tell patients found to be HIV-positive their diagnosis.

  2. 18

    In late 2001, the Irish embassy in Mozambique granted Mr. Uamusse funding to open a sewing school for the widows and orphans of former miners. One of Elisa’s daughters is now a student at this school.

  3. 19

    See Wilson et al., “An AIDS Assessment of the Maputo Corridor: Ressano Garcia to Chokwe and Vilankulo.”

  4. 20

    See Joseph Collins and Bill Rau, “AIDS in the Context of Development,” UNRISD Program on Social Policy and Development Paper No. 4 (UNRISD/UNAIDS, December 2000); and Paul Farmer, Infections and Inequalities: The Modern Plagues (University of California Press, 1999).

  5. 21

    Six months after I met her, I learned that Elisa did get her pension money, but she had to go to South Africa to collect it after all.

  6. 22

    Former Mine Workers Yet to Claim Compensation,” AIM Reports, September 11, 2001.

  7. 23

    Neil White, “Dust-Related Diseases in Former Miners—the ODMWA Legacy,” Occupational Health Southern Africa, July/August 1997, pp. 20–24.

  8. 24

    World Development Report 2002: Building Institutions for Markets (World Bank/Oxford University Press, 2002).

  9. 25

    Peter R. Lamptey, “Reducing Heterosexual Transmission of HIV in Poor Countries,” British Medical Journal, January 26, 2002, pp. 207–211.

  10. 26

    Malyn Newitt, A History of Mozambique (Johannesburg: Witwatersrand University Press, 1995).

  11. 27

    The Victorians also suffered from sexually transmitted diseases, which they blamed on prostitutes. In fact, the spread of sexually transmitted diseases in Victorian times may have been similar to the spread of HIV in Mozambique today, in that it was driven partly by economic changes that created legions of impoverished women with few alternatives besides prostitution, and prevailing attitudes that let men get away with adultery but punished women for it.

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