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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?

Xai Xai lies on the coast about 150 miles east of Maputo on the main road that miners travel on from their home villages to the South African mines. Mr. Uamusse said he knew a lot of mining families in Xai Xai that were suffering because of AIDS, and through his union he was trying to find ways to help them.

Mr. Uamusse, a former miner himself, was about forty years old. He was tall, with a long, oval face, and he wore the frayed pieces of an old green suit, and a pair of broken sandals held on with string. His mission, he said, was “the vindication of miners’ rights, and the improvement of their social and economic condition.” In practice, this meant writing letters of inquiry to the American Mineworkers’ Union, the AFL-CIO, the International Labor Organization, and other institutions requesting funds. To these letters, Mr. Uamusse received few replies, although he had managed to raise a few thousand dollars which he said he was using to conduct lectures on the dangers of AIDS to new recruits at the mine induction center near the border. He was also making a list of all the families that had been affected by AIDS in Xai Xai, and he had a consignment of sewing machines that he was distributing to the widows of miners who had died of AIDS so they could earn some money making and repairing clothes.

The drive to Xai Xai took three hours, and Mr. Uamusse talked nearly the entire time. The AIDS problem in the rural communities around here was caused by immoral behavior, he said, but not so much on the part of migrant miners. It was the women who were the problem. Because the men were always away, they were not able to impose discipline on their families. “Say you get a wife,” he said hypothetically, “and then you go to South Africa to work. You come back twelve months later, and you find that wife pregnant. You find you have to fire that wife. Then you get another one, and that one is also unfaithful. This is what is happening.” He approved of the fact that the mining companies in South Africa distributed condoms to their workers, but he did not believe they should be given to women, because it encouraged disrespect and promiscuous behavior. Mr. Uamusse’s views seemed to be widely held in Mozambique. Condoms are cheap and generally available, but only nine million were sold last year, two for every male adult in the country.

It was late afternoon, and the countryside glowed in the shallow sunlight. Xai Xai lies in a flood plain near the Limpopo River and the Indian Ocean. In recent years, oceanic cyclones have pelted this region with terrible floods, but now it was the dry season and plumes of dust blew off the fields into the clear sky, warning of drought. The road was smooth and fast and there was little traffic, except for the buses, of which there were two kinds, Mozambican and South African. The Mozambican buses are great wheezing wrecks, belching smoke, traveling at thirty miles an hour and stopping everywhere. Teetering on the roof are huge bundles of pineapples, charcoal, and maize meal, which occasionally fall off. I had ridden on one of these buses a few days before, and as it drew nearer to the city, it soon became so crowded that passengers near the door could fit inside only if they all turned their heads in the same direction and pressed them up against the ceiling. Sleek new South African buses sped past us. These buses are almost exclusively used by returning mine workers, and they all tow small trailers loaded with goods—televisions and stereos still in their cartons, bicycles and mattresses wrapped in plastic—that are luxury items in this part of the world.

Miners earn relatively high salaries compared to other Mozambicans, and they are among the richest people in these communities. But mining is also dangerous work. About one in thirty miners doesn’t make it out of the mines alive, and about half are permanently disabled by the end of their careers. Miners in southern Africa have the highest rates in the world of tuberculosis and silicosis—a severe immune reaction to silica dust that destroys the lungs. But a miner’s greatest fear is that the walls of the mine will cave in behind him, trapping or crushing him. When this happens the shock waves can travel for hundreds of kilometers. “It was like an earthquake, we could feel it in the hostels and then we knew people were being killed,” Mr. Uamusse said. There are other dangers too. The miners come from all over southern Africa, and workers on the same mine may speak ten or more languages. Sometimes tensions arise in the cramped, all-male hostels. Sometimes there are fights, and sometimes the men kill each other, he said.

However, in southern Mozambique, men cherish a job in the South African mines, because the local economy is a shambles. Mozambique is often cited as a development success story, and according to the World Bank, its economy is growing strongly. However, most of this growth is confined to Maputo, the capital city.11 Rural incomes have been rising far more slowly, if at all. Agriculture, which supports most Mozambicans, grew by only 1 percent in 2000. The construction industry and a single aluminum smelting plant in the southern region account for most of the nation’s recent growth. Money earned illegally may also be contributing to Mozambique’s ostensibly remarkable economic growth. For example, Joseph Hanlon, a writer and expert on southern Africa, estimates that a ton each of cocaine and heroin pass through the ports of Mozambique every month on their way to the US and Europe.12 Mozambique was once one of the most industrialized countries in Africa. Its factories produced clothing, textiles, furniture, processed cashews, and other commodities. Many farming families from Xai Xai supplemented their sometimes precarious incomes by working in these industries. The Portuguese colonial government protected these industries with import tariffs and subsidies and other Portuguese territories provided a guaranteed market. But most of these businesses were operated by Portuguese businessmen, who fled after independence in 1975. The new black Mozambican government took them over, but could not afford to maintain them. Local industries suffered even more after the onset of a bloody, roughly decade-long war in the 1980s.

The war, the lingering effects of the oil crisis of the late 1970s, a shaky global economy, and the development blunders of Mozambique’s inexperienced new leaders all sank the country deeper into debt. Then, in the mid- 1980s and again in the mid-1990s, the World Bank and International Monetary Fund informed the Mozambican government that they would continue to lend the country money only if it stopped supporting its struggling industries. The lenders, following the neoliberal development ideas of US and Western European leaders at the time, believed that developing countries would prosper if they reduced government spending and protectionist trading practices. Freer trade would, in theory, integrate these countries into the global economy so they would grow more quickly. This, in turn, would help ensure that countries like Mozambique would be in a better position to service their debts.

In effect, these policies helped to ruin many of Mozambique’s industries.13 Now, in a nation of 20 million people, only about 600,000 have formal jobs. The rest mainly work in the “informal sector” as subsistence farmers or petty traders. Some 120,000 people have been thrown out of work since 1987 because the companies that once employed them could not stay in business and rebuild after the chaos and destruction of the war, when the government abruptly privatized them or eliminated duties and subsidies. Meanwhile, throughout the 1990s, corrupt government cronies and shady businessmen “borrowed” from Mo-zambique’s newly privatized banks hundreds of millions of dollars that might have been invested in these businesses. This money was never repaid, and millions more were lost through accounting fraud.

Mozambique’s banks also became notorious for illegal foreign exchange deals, money laundering, and other criminal activities. Since 1997, two executives and one journalist investigating the banking system in Mozambique have been murdered, and several others have been shot at, but not killed. While government officials were ultimately responsible for Mozambique’s banking crisis, the World Bank and IMF may also bear some responsibility, because they put pressure on the government to privatize the banks quickly, before regulatory and accounting systems that might have reduced the risks of fraud could be put in place.14

Now, the prices that farmers get for their cashews are even lower than they were before the export restrictions were scrapped, because the export market turned out not to be as buoyant as the economists expected, and most of the local processing plants have now closed.15 Most people now wear textiles from India and secondhand clothes imported from West-ern countries. The market is also flooded with manufactured goods imported, often illegally, from neighboring countries, including South Africa. These imports often cost the same, and sometimes even more than, the products Mozambicans used to make themselves.

Most Mozambicans are peasant farmers, but life is not easy for them either. The weather is erratic and the terms of trade are very poor. One farmer I met who grew mangoes and maize said she earned about six dollars a week, on which she supported a family of eleven. Many small farms were destroyed during the war, and their peasant owners struggle to build them up again. They need new farm implements, seeds, cattle, irrigation systems, roads, and trading networks to get their goods to the market. It has been argued that the government should do more to help them. Some farmers have access to small credits and development funds, but these programs do not reach everyone who needs help.

Because the harvest is not always reliable, for generations Mozambican farmers have supplemented their incomes with wage labor, either in factories or in the South African mines.16 But the factories are failing, and because the price of gold has dropped in recent years, and, in any case, the gold mines are nearly exhausted, many miners are now being laid off as well.

Mr. Uamusse and I drove past the ruins of buildings destroyed in the war, and villages hidden among shady trees. Stout women peasants in kerchiefs and long skirts hammered the earth with their hoes and goats trotted to and fro across the empty road. Mr. Uamusse wanted me to go back to America and find people to invest in southern Mozambique. “Now see here,” he said, “we have been driving for nearly two hours, and we have not passed a single town. Why don’t they put a town here?” I said I thought that was a good question. “Why don’t they put up a factory in this area? We have mangoes, cashews, coconut…. We could make jam, we could make oils—oils for cooking, oils for beauty…. We could use the clay to make bricks….”

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. 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).

  11. 11

    See Mozambique National Human Development Report (UNDP, 2000); “MOZAL Responsible for 60 Percent of Exports,” AIM Reports, No. 217, October 15, 2001; and “Growth Lower than Expected in 2000,” AIM Reports, No. 205, April 20, 2001.

  12. 12

    See “Drug Trafficking Is Big Business in Mozambique,” AIM Reports, No. 210, June 29, 2001.

  13. 13

    Joseph Hanlon, Peace without Profit: How the IMF Blocks Rebuilding in Mozambique (Heinemann, 1996). Industries in other countries have been adversely affected by such policies as well. See, for example, Pádraig Carmody, Tearing the Social Fabric: Neoliberalism, Deindustrialization, and the Crisis of Governance in Zimbabwe (Heinemann, 2001). For a critique of World Bank/IMF development policies in general, see Joseph Stiglitz, Globalization and its Discontents (Norton, 2002).

  14. 14

    Joseph Hanlon, “Banking in the Transition from Socialism to Capitalism in Mozambique, and the Struggle to Maintain a Developmental Focus,” Review of African Political Economy, March 2002, pp. 41–60. Views about how liberal economic reforms have unintentionally contributed to government corruption can also be found in Jean-François Bayart, Stephen Ellis, and Béatrice Hibou, The Criminalization of the State in Africa (Indiana University Press, 1999).

  15. 15

    Paul Krugman and others have defended the World Bank’s cashew policy in Mozambique (see “Lost in Cyberspace,” The New York Times, April 19, 2000). They argue that eliminating protection for the cashew industry should enable rural farmers to get better prices for their raw cashews, because they can sell them on the world market. However, removing protection actually hurt Mozambique’s rural farmers, because many women from farming families worked in the (now largely defunct) cashew industry and farming families depended on their wages. In addition, after the regulations were scrapped, the prices of raw cashews fell, contrary to the economists’ expectations. Preventing poor countries from protecting their industries, especially when the countries are recovering from conflict, seems particularly unfair when the US and European Union continue to maintain strong protective trade barriers for their own agricultural, textile, and steel industries.

  16. 16

    See Merle L. Bowen, The State Against the Peasantry: Rural Struggles in Colonial and Postcolonial Mozambique (University Press of Virginia, 2000).

  17. 17

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

  18. 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.

  19. 19

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

  20. 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).

  21. 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.

  22. 22

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

  23. 23

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

  24. 24

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

  25. 25

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

  26. 26

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

  27. 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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