AIDS IN AFRICA
In Search of the Truth
By Rian Malan
Rolling Stone 22 Nov. 2001
Dear Jann,
You will be saddened to hear that Adelaide Ntsele has died. As you may
recall, she featured briefly in my article a year ago about the long,
twisted history of the song, "The Lion Sleeps Tonight," which was based on
a melody composed by her father, Solomon Linda. While I interviewed her
sisters about the life and times of their father, the great Zulu singer,
Adelaide was swooning feverishly under greasy blankets. She got up from
her sickbed only to have her picture taken. She was so weak she could
barely stand, but she wanted to be in your magazine.
I took her to hospital afterward. We sat in Emergency for a long time,
waiting for attention. Her sister Elizabeth was there, too. She's a nurse.
She looked at Adelaide's hospital card and grew very quiet. Later, she
told me there was a symbol indicating that Adelaide had come up positive
on an HIV test. Atop that she had tuberculosis and a gynecological
condition that required surgery. The operation had already been postponed
repeatedly. To Elizabeth, it looked like the the doctors had decided,
"Well, this one's had it, she'll die anyway, just let it happen." And so
it did.
A year ago, the funeral scene would have written itself. I would have
described the kindly old pastor, the sad African singing, the giant iron
pots on fires for the ritual goodbye feast. I would have mentioned the
eerie absence of any reference to AIDS in the eulogies and made some rote
observation about the denial it betokened. I would have scanned the faces
of mourners, trying to pick out the one in five who were carriers of the
virus that put Adelaide in her coffin, withered and shriveled like a
child. And in the end I would have turned sadly away, lamenting a society
that allowed a thirty-seven-year-old woman to die because she couldn't
afford the drugs available to rich white people.
Instead, I spent the ceremony thinking about viral antigens,
cross-reactions and other mysteries of what Sowetans call H.I.Vilakazi,
the scourge of the deadly three letters. Then, midway through the
proceedings, the pastor broke my reverie; Perhaps the visitors would like
to say something? I rose to my feet, straightened my tie and prepared to
speak my mind, but courage failed me, so I mumbled a few platitudes
instead. "It is a heartbreak that Adelaide was taken so young," I said.
"She bore terrible suffering with enormous dignity," I said. "We will
always remember her as she appears in that picture," I concluded, nodding
toward a framed portrait of a wistful young woman with huge doe eyes and
haunting cheekbones like Marlene Dietrich's. Adelaide wanted to be a
model. She never made it. I extended my condolences to the family and sat
down again.
It wasn't the eulogy Adelaide deserved, but then it wasn't the right
time or place for a great cry of rage and confusion, either. But now the
mourning is done, and there are things that must be said.
My first mistake
Africa's era of megadeath dawned in the fall of 1983, when the chief of
internal medicine of a hospital in what was then Zaire sent a communique
to American health officials, informing them that a mysterious disease
seemed to have broken out among his patients. At the time, the United
States was being convulsed by its own weird health crisis. Large numbers
of gay men were coming down with an unknown disease of extraordinary
virulence, something never seen in the West before. Scientists called it
GRID, an acronym for Gay-Related Immune Deficiency. Political
conservatives and holy men called it God's vengeance on sinners. American
researchers were thus intrigued that a similar syndrome had been observed
in heterosexuals in Africa. A posse of seasoned disease cowboys was
convened and sent forth to investigate.
On October 18th, 1993, they walked into Kinshasa's Mama Yemo Hospital,
led by Peter Piot, 34, a Belgian microbiologist who had been to the
institution years earlier, investigating the first outbreak of Ebola
fever. A change was immediately apparent. "In 1976, there were hardly any
young adults in orthopedic wards," Piot told a reporter. "Suddenly - boom
- I walked in and saw all these young men and women, emaciated, dying."
Tests confirmed his worst apprehensions: The mysterious new disease was
present in Africa, and its victims were heterosexual. When researchers
started looking for the newly identified human immunodeficiency virus, it
turned up almost everywhere - in eighty percent of Nairobi prositutes,
thiry-two percent of Ugandan truck drivers, forty-five percent of
hospitalized Rwandan children. Worse, it seemed to be spreading very
rapidly. Epidemiologists plotted figures on graphs, drew lines linking the
data points and gaped in horror. The epidemic curve peaked in the
stratosphere. Scores of millions - maybe more - would die unless something
was done.
These prophecies transformed the destiny of AIDS. In 1983, it was a
fairly rare disease, confined largely to the gay and heroin-using
subcultures of the West. A few years later, it was a threat to all of
humanity itself. "We stand nakedly before a pandemic as mortal as any
there has ever been," World Health Organization chief Halfdan Mahler told
a press conference in 1986. Western governments heeded his anguished
appeal for action. Billions were invested in education and prevention
campaigns. According to the Washington Post, impoverished AIDS researchers
suddenly had budgets that outstripped their spending capacity.
Nongovernmental AIDS organizations sprang up all across Africa - 570 of
them in Zimbabwe, 300 in South Africa, 1,300 in Uganda. By 2000, global
spending on AIDS had risen to many billions of dollars a year, and
activists were urging the commitment of many billions more, largely to
counter the apocalypse in Africa, where 22 million were said to carry the
virus and 14 million to have died of it.
And this is about where I entered the picture - July 2000, three months
after South African President Thabo Mbeki announced that he intended to
convene a panel of scientists and professors to re-examine the
relationship between the human immunodeficiency virus and AIDS. Mbeki
never exactly said AIDS doesn't exist, but his action begged the question,
and the implications were mind-bending. South Africa was said to have more
HIV infections (4.2 million) than any other country on the planet. One in
five adults were already infected, and the toll was rising daily. As his
words sank in, disbelief turned to derision.
"Ludicrous," said the Washington Post.
"Off his rocker," said the Spectator.
"A little open-mindedness is fine," said Newsday. "But a person can be
so open-minded, his brains can fall out."
The whole world laughed, and I rubbed my hands with glee: South Africa
was back on the world's front pages for the first time since the fall of
apartheid; fortune awaited the man of action. I went to see a friend who
happens also to be an AIDS epidemiologist. He was so enraged by what he
called the "genocidal stupidity" of Mbeki's initiative that he'd left work
and gone home, where I found him slumped in depression. "Hey," I said,
snap out of it. Let's make a deal." And so we did: He'd talk, I'd type,
and together we'd tell the inside story of Thabo Mbeki's AIDS fiasco. All
that remained was to consider to consider the evidence that had led our
leader astray.
According to newspaper reports, Mbeki had gleaned much of what he knew
from the Web, so I revved up the laptop and followed him into the virtual
underworld of AIDS heresy, where renegade scientists maintain Web sites
dedicated to the notion that AIDS is a hoax, dreamed up by a diabolical
alliance of pharmaceutical companies and "fascist" academics whose only
interest is enriching themselves. I visited several such sites, noted what
they had to say, and then turned to Web sites maintained by universities
and governments, which offered crushing rebuttals. Can't say I understood
everything, because the science was deep and dense, but here's the gist:
Look at AIDS from an African point of view. Imagine yourself in a mud
hut, or maybe a tin shack on the outskirts of some sprawling city. There's
sewage in the streets, and refuse removal is nonexistent. Flies and
mosquitoes abound, and your drinking water is probably contaminated with
feces. You and your children are sickly, undernourished and stalked by
diseases for which you're unlikely to receive proper treatment. Worse yet,
these diseases are mutating, becoming more virulent and drug-resistant.
Minor scourge such as diarrhea and pneumonia respond sluggishly to
antibiotics. Malaria now shrugs off treatment with chloroquine, which is
often the only drug for it available to poor Africans. Some strains of
tuberculosis - Africa's other great killer - have become virtually
incurable. Now atop all this is AIDS.
According to what you hear on the radio, AIDS is caused by a tiny virus
that lurks unseen in the blood for many years, only to emerge in deep
disguise: a disease whose symptoms are other diseases, like TB, for
instance. Or pneumonia. Running stomach, say, or bloody diarrhea in
babies. These diseases are not new, which is why some Africans have always
been skeptical, maintaining that AIDS actually stands for "American Idea
for Discouraging Sex." Others say nonsense, the scientists are right,
we're all going to die unless we use condoms. But condoms cost money and
you have none, so you just sigh and hope for the best.
Then one day you get a cough that won't go away, and you start shedding
weight at an alarming rate. You know these symptoms. In the past, you
could take some pills and they would usually go away. But the medicines
don't work anymore. You get sicker and sicker. You wind up in the AIDS
ward.
The orthodox scientists, if they could see you lying there, would say
your immune system has been destroyed by HIV, allowing the tuberculosis
(or whatever) to run riot. The dissidents would say no way - the virus is
a harmless creature that just happens to accompany immune-system breakdown
caused by other factors, in this case a lifetime of hunger and exposure to
tropical pathogens.
Incensed by this, the orthodoxy whistles up a truckload of studies from
all over Africa showing that HIV-positive hospital patients die at
astronomical rates relative to their HIV-negative counterparts. The
dissidents claim to be unimpressed. This proves nothing, they say except
that dying hospital patients carry the virus.
The orthodoxy grits its teeth. There's only one way to crush these
rebels, and that's to show that AIDS is a new disease that has caused a
massive increase in African mortality, which is of course the truth as we
know it: 22 million Africans infected, with 14 million more already dead
from it.
These frightening numbers were all that mattered, it seemed to me. Once
they were shown to be accurate, further debate would be rendered obscene,
and Thabo Mbeki would be guilty as charged, a fool who'd allowed himself
to be swayed by a tiny band of heretics universally dismissed as wackos,
fringe lunatics and scientific psychopaths. So I set out to confirm the
death toll. Just that. I thought it would be easy - a call or two, maybe a
brief interview. I picked up the phone. It was my first mistake.
A Forbidden Thought
There was a time when I imagined medical research as an idealized
endeavor, carried out by scientists interested only in truth. Up close, it
turns out to be much like any other human enterprise, riven with envy,
ambition and the standard jockeying for position. Labs and universities
depend on grants, and grantmaking is fickle, subject to the vagaries of
politics and intellectual fashion, and prone to favor scientists whose
work grips the popular imagination. Every disease has champions who gather
the data and proclaim the threat it poses. The cancer fighters will tell
you that their crisis is deepening, and more research money is urgently
needed. Those doing battle with malaria make similar pronouncements, as do
those working on TB, and so on, and so on. If all their claims are added
together, you wind up with a theoretical global death toll that "exceeds
the number of humans who die annually by two- to threefold," said
Christopher Murray, a World Health Organization director.
Malaria kills around 2 million humans a year, roughly the same number
as AIDS, but malaria research currently gets only a fraction of the
resources devoted to AIDS. Tuberculosis (1.7 million victims a year) is
similarly sidelined, to the extent that there were no new TB drugs in
development at all as of 1998. AIDS, on the other hand, is replete,
employing an estimated 100,000 scientists, sociologists, caregivers,
counselors, peer educators and stagers of condom jamborees. Until the
attacks of September 11th diverted the world's anxieties (and charity
dollars), the level of funding for AIDS grew daily as foundations,
governments and philanthropists such as Bill Gates entered the field,
unnerved by the bad news, which usually arrived in the form of articles
describing AIDS as a "merciless plague" of "biblical virulence," causing
"terrible depredation" (as Time recently put it) among the world's
poorest people.
These stories all originate in Africa, but the statistics that support
them emanate from the suburbs of Geneva, where the World Health
Organization has its headquarters. Technically employed by the United
Nations, WHO officials are the world's disease police, dedicated to
eradicating illness. They crusade against old scourges, raise the alarm
against new ones, fight epidemics, and dispense grants and expertise to
poor countries. In conjunction with UNAIDS (the joint United Nations
Programme on HIV/AIDS, based at the same Geneva campus), the WHO also
collects and disseminates information about the AIDS pandemic.
In the West, the collection of such data is a fairly simple matter:
Almost every new AIDS case is scientifically verified and reported to
government health authorities, who inform the disease police in Geneva.
But AIDS mostly occurs in Africa, where hospitals are thinly spread,
understaffed and often bereft of the laboratory equipment necessary to
confirm HIV infections. How do you track an epidemic under these
conditions? In 1985, the WHO asked experts to hammer out a simple
description of AIDS, something that would enable bush doctors to recognize
the symptoms and start counting cases, but the outcome was a fiasco -
partly because doctors struggled to diagnose the disease with the naked
eye, but mostly because African governments were too disorganized to
collect the numbers and send them in. Once it become clear that the
case-reporting system wasn't working, the WHO devised an alternative, by
which Africa's AIDS statistics are now primarily based.
It works like this: On any given morning anywhere in sub-Saharan
Africa, you'll find crowds of expectant mothers ling up outside government
prenatal clinics, waiting for a routine checkup that includes the drawing
of a blood sample to test for syphilis. According UNAIDS, "anonymous blood
specimens left over from these tests are tested for antibodies to HIV," a
ritual that usually takes place once a year. The results are fed into a
computer model that uses "simple back-calculation procedures" and
knowledge of "the well-known natural course of HIV infection" to produce
statistics for the continent In other words, AIDS researchers descend on
selected clinics, remove the leftover blood samples and screen them for
traces of HIV The results are forwarded to Geneva and fed into a computer
program called Epi-model: If a given number of pregnant women are
HIV-positive, the formula says, then a certain percentage of all adults
and children are presumed to be infected, too. And if that many people are
infected, it follows that a percentage of them must have died. Hence, when
UNAIDS announces 14 million Africans have succumbed to AIDS, it does not
mean 14 million infected bodies have been counted. It means that 14
million people have theoretically died, some of them unseen in Africa's
swamps, shantytowns and vast swaths of terra incognita.
You can theorize at will about the rest of Africa and nobody will ever
be the wiser, but my homeland is different - we are a semi-industrialized
nation with a respectable statistical service. "South Africa," says Ian
Timaeus, London School of Hygiene and Tropical Medicine professor and
UNAIDS consultant "is the only country in sub-Saharan Africa where
sufficient deaths are routinely registered to attempt to produce national
estimates of mortality from this source." He adds that, "coverage is far
from complete," but there's enough of it to be useful - around eight of
ten deaths are routinely registered in South Africa, according to Timaeus,
compared to about 1 in 100 elsewhere below the Sahara.
It therefore seemed to me that checking the number of registered deaths
in South Africa was the surest way of assessing the statistics from
Geneva, so I dug out the figures. Geneva's computer models suggested that
AIDS deaths here had tripled in three years, surging from 80,000-odd in
1996 to 250,000 in 1999. But no such rise was discernable in total
registered deaths, which went from 294,703 to 343,535 within roughly the
same period. The discrepancy was so large that I wrote to make absolutely
sure I had understood these numbers correctly. Both parties confirmed that
I had, and at that exact moment, my story was in trouble. Geneva's figures
reflected catastrophe. Pretoria's figures did not. Between these extremes
lay a gray area populated by local experts such as Stephen Kramer, manager
of insurance giant Metropolitan's AIDS Research Unit, whose own computer
model shows AIDS deaths at about one-third Geneva's estimates. But so
what? South African actuaries don't get a say in this debate. The figures
you see in your newspapers come from Geneva. The WHO takes pains to label
these numbers estimates only, not rock-solid certainties, but still, these
are estimates we all accept as the truth.
But you don't want to hear this, do you? Nor did I. It spoiled the
plot, so I tried to ignore it. Since it was indeed true that the very
large numbers of South Africans were dying, then the nation's coffin
makers had to be laboring hard to keep pace with growing demand. One
newspaper account I found told of a company called Affordable Coffins,
purveyor of cheap cardboard caskets, which had more orders than it could
fill. But the firm was barely two months old when the story ran, and two
rival entrepreneurs who launched similar products a few years back had
gone under. "People weren't interested." said a dejected Mr. Rob Whyte.
"They wanted coffins made of real wood."
So I called the real-wood firms, three industrialists who manufactured
coffins on an assembly line for the national market. "It's quiet," said
Kurt Lammerding of GNG Pine Products. His competitors concurred - business
was dead, so to speak.
"It's a fact," said Mr. A. B. Schwegman of B&A Coffins. "If you go on
what you read in the papers, we should be overwhelmed, but there's
nothing. So what's going on? You tell me."
I couldn't, although I suspected it might have something to do with
race. Since the downfall of apartheid, in 1994, illegal backyard funeral
parlors have mushroomed in the black townships, and my sources couldn't
discount the possibility that these outfits were scoring their coffins
from the underground economy. So, I called a black-owned firm, Mmabatho
Coffins, but it had gone out of business, along with some others I tried
calling. This was getting seriously weird. The death rate had almost
doubled in the past decade, according to a recent story in South Africa's
largest newspaper. "These aren't projections," said the Sunday Times.
"These are the facts." And if the facts were correct, I thought, someone
somewhere had to be prospering in the coffin trade.
Further inquiries led me to Johannesburg's derelict downtown, where a
giant multistory parking garage has recently been transformed into a vast
warren of carpentry workshops, each housing a black carpenter, set up in
business with government seed money. I wandered around searching for
coffin makers, but there were only two. Eric Borman said business was
good, but he was a master craftsman who made one or two deluxe caskets a
week and seemed to resent the suggestion his customers were the sort of
people who died of AIDS. For that, I'd have to talk to Penny. Borman
pointed, and off I went, deeper and deeper into the maze. Penny's place
was locked up and deserted. Inside, I saw unsold coffins stacked
ceiling-high, and a forlorn CLOSED sign hung on a wire.
At that moment, a forbidden thought entered my brain. This may sound
crazy to you, thousands of miles away, but put yourself in my shoes. You
live in Africa - OK , in the post-colonial twilight of Johannesburg's
once-white suburbs, but still, close enough to the AIDS front line. For
years, experts tell you that the plague is marching down the continent,
coming ever closer. At first nothing happens, but there dawns a day when
the HIV estimates start rising around you, and by 2000 the newspapers are
telling you that one in five adults on your street is walking dead.
This has to be true, because it's coming from experts, so you start
looking for evidence. Laston, the gardener at Number 10, is suspiciously
thin, and has a hacking couch that won't go away. On the far side of the
golf course, Mrs. Smith has just buried her beloved servant. Mr.
Beresford's maid has just died, too. Your cousin Lenny knows someone who
owns a factory where all the workers are dying. Your newspapers are
regularly predicting that the economy will surely be crippled, and
schooling may soon collapse because so many teachers have died.
But then you find yourself staring into Penny's failed coffin workshop
and you think, Jesus, maybe something is wrong here...
Is this likely? Look, I believe that AIDS exists and it's killing
Africans. But as many as all the experts tell us? Hard to say. In my
suburb, I can assure you, people's brains are so addled by death
propaganda that we automatically assume almost everyone who falls
seriously ill or dies has AIDS, especially if they're poor and black. But
we don't really know for sure, and nor do the sufferers themselves,
because hardly anyone has been tested. "What's the point?" asks Laston,
the ailing gardener. He knows there's no cure for AIDS, and no hope of
obtaining life-extending anti-retrovirals. Last winter, he came down with
a bad cough, and everyone said it was AIDS, but it wasn't - come summer,
Laston got better. Then Stanley the bricklayer became our street's most
likely case. Stan maintained he had a heart condition, but behind his
back, everyone was whispering, "Oh, my God, it's AIDS." But was it? We had
no idea. We were playing a game, driven by hysteria.
No one wanted to hear this. Worried friends slipped newspaper clippings
into my mailbox: CEMETERY OVERFLOWS....HOSPITALS OVERWHELMED....PRISON
DEATHS UP 535 PERCENT. I checked out all the evidence, but often there was
some other possible explanation, like cut-price burial plots or a TB
epidemic in the overcrowded jails or a funding crisis in government
hospitals. After months of this, even my mother lost patience. "Shut up!"
she snapped. "They'll put you in a straitjacket." Mother knows best, but I
just couldn't get those numbers out of my head: 294,703 registered deaths
in 1996, 343,535 four years later. I called my friend the AIDS
epidemiologist and said, "Listen, I am beset by demons and heresies, can
you not save me?" So we had lunch, and I aired my doubts, whereupon he
pointed in the direction where truth lay, and I set out to find it.
A Bell is Rung
And here we are on a hilltop on the equator, overlooking the landscape
where Africa's first recorded outbreak of AIDS took place. It's a village
called Kashenye, which lies on the border between Uganda and Tanzania.
close to where the Kagera River flows into Lake Victoria. In 1979 or
thereabouts, according to local legend, a trader crossed the river in a
canoe to sell his wares in Kashenye. Business done, he bought some beers
and relaxed in the company of a village girl. Some time later, she fell
victim to a wasting disease that refused to respond to any known
medication, Western or tribal.
Not long after, according to Edward Hooper in his book Slim, a
similar drama unfolded in Kasensero, a fishing village over on the Uganda
side of the river. There the first victim was also a local girl, and the
agent of infection was said to have been a visitor from Kashenye. In due
course, several more citizens of Kashenye contracted the wasting disease.
Their neighbors cried foul, accusing Kashenye of putting a hex on them.
Kashenye responded with similar allegations. Soon, villagers on both banks
of the river were discarding objects brought from the other side,
believing them to be bewitched. But nothing helped. By 1983, the contagion
was in all the cities on the Western shore of Lake Victoria. Within a few
years the region became known as the epicenter of Africa's AIDS epidemic,
and Ugandan president Yoweri Museveni was predicting that "apocalypse" was
imminent.
His prophesy was based largely on testing done among small groups of
high-risk subjects. Many factors were unknown, however, including the true
extent of infection in the general populace, the rate at which it was
spreading, the speed at which it killed. To formulate an effective battle
plan, AIDS researchers desperately needed more data in these areas.
They cast around for a place to study, and lit on the Masaka district
in Uganda, a ramshackle area just west of Lake Victoria and probably 100
miles north of Ground Zero. The rate of infection there among adults was
not particularly high - just more than eight percent - but there were
other considerations making it a good place to study: The district was
politically stable, and there was an international airport three hours
away. In 1989, a Dutch epidemiologist named Daan Mulder began to lay the
groundwork for what would ultimately become the longest and most important
study of its kind in Africa.
Assisted by an army of of field workers, Mulder drew a circle around
fifteen villages outside Masaka and proceeded to count every resident.
Then he took blood from all those who were willing - 8,833 out of 9,777
inhabitants - screened it for HIV infections and sat back to see what
happened. Every household was visited at least once a year, and every
death was noted and entered into Mulder's database, along with the
deceased's HIV status.
The first results were published in 1994, and they were devastating.
The HIV-infected villagers of Masaka were dying at a rate fifteen times
higher than their uninfected neighbors. Young adults with the virus in
their bloodstream were sixty times more likely to perish. Overall,
HIV-related disease accounted for a staggering forty-two percent of all
deaths. The AIDS dissidents were crushed, HIV theory was vindicated. "If
there are any left who will not even accept [this]," commented the U.S.
Centers for Disease Control upon the release of the results, "their
explanation of how HIV-seropositivity leads to early death must be very
curious indeed."
Clearly, only a fool would second-guess such powerful evidence, so I
just visited the villages where Mulder's work was done, verified what he'd
found and headed back toward the airport, my story about Mbeki's stupidity
back on track. But on my way I spent an hour or two in Uganda's Statistics
Office, and what I learned there changed things yet again.
In 1948, Uganda's British rulers attempted a rough census in the Masaka
area and concluded that the annual death rate was "a minimum of
twenty-five to thirty per thousand." A second census, in 1959, put the
figure at twenty-one deaths per thousand. By 1991, it had fallen to
sixteen per thousand. Enter Daan Mulder with his blood tests, massive
funding and armies of field workers. He counted every death over two
years, and then five, and here is his conclusion: The crude annual death
rate in Masaka, in the midst of a horrifying AIDS plague, was 14.6 per
thousand - the lowest ever measured.
I was relieved to discover that there was another possible
interpretation of these statistics. Daan Mulder's work began at a time
when Uganda was emerging from two decades of terror and chaos. Doctors had
fled the country, hospitals had collapsed and nobody kept track of
mortality trends in the dark years of the Seventies and Eighties.
According to British statistician Andrew Nunn, one of Mulder's
collaborators, disease-related rates must have fallen to all-time low
levels in the Seventies, when no one was counting, and then surged
massively with the advent of AIDS around 1980.
"In fact," says Nunn, "evidence suggests it's epidemic." (Mulder
himself cannot be asked to explain his findings - he has since died of
cancer.)
Nunn's explanation may be so, but the same can't apply to neighboring
Tanzania, which embarked in 1992 on an even larger mortality study. Like
Mulder's, it was funded by the British government and supported by
scientists from the British universities. The Adult Morbidity and
Mortality Project recruited 307,912 participants, each of whom was visited
at least once a year in the next three years and questioned about recent
deaths or disease. The final results were rather like Masaka's: AIDS was
the leading reported cause of adult mortality, but the average death rate
in the communities studied was 13.6 per thousand - ten percent lower than
the death rate measured in the census of 1988, which was rated "close to
100 percent" complete by Dr. Timaeus, the UNAIDS consultant. Timaeus is a
leading authority on African mortality in th AIDS era, and it was to him
that my difficult question ultimately fell.
Professor Timaeus," I said in his London office, "this study appears to
show that there was no increase in the death rate between 1988 and 1995,
in the heart of Tanzania's AIDS epidemic."
He shrugged. "This survey covered only part of the country," he said.
"True," I said, "but a fairly large part, with hundreds of thousands of
participants."
"But were they representative?" he countered.
I had no idea. Timaeus smiled and said, "I think this is the
more critical evidence."
Whereupon he produced a sheath of graphs and papers and laid them on
the table. There was, he said, a "regrettable" lack of knowledge about
mortality trends in Africa, attributable to "inertia," indifference and a
crippling lack of up-to-date data. These factors bedeviled the
demographer, but Timaeus said he knew of several ways around them, most
dramatic of which is the so-called sibling-history technique of mortality
estimation. It works like this:
Since 1984, researchers financed by the U.S. Agency for International
Development have conducted detailed health interviews with several
thousand mothers in developing countries worldwide. Among the questions
put to them are these: How many children did your mother have? How many
are still alive? When did the others die? Timaeus realized that close
analysis of the answers might reveal trends that were failing to show up
elsewhere. He set to work, and published the results in the journal
AIDS in 1998. "In just six years (1989-1995) in Uganda," he wrote,
"men's death rates more than doubled." Similar trends were revealed in
Tanzania, he reported, where "men's deaths apparently rose eighty percent"
in the same period.
Again, this seemed to settle the matter, but again, there were puzzling
complications. For a start, Timaeus' study coincided with Daan Mulder's
epic mortality study, which ran for seven years without detecting any
significant change in the death rate. The same is true of Tanzania's giant
adult-mortality survey, which fell in the heart of the period when Timaeus
says male mortality was surging upward but which failed to document any
such thing.
Could there have been some problem with Timaeus' data? Kenneth Hill is
the Johns Hopkins university demographer who helped conceive the
sibling-history technique. Recently, he and his team embarked on a
worldwide evaluation of its performance in the field, to check on its
accuracy. Last year, an article co-authored by Hill reported that the
method was prone to something called, "downward bias" - meaning that
people remember recent deaths pretty clearly, but those from years back
tend to fade. According to the article, which appeared in Studies in
Family Planning, this usually leads to a false impression of rising
mortality rates as you near the present. This has happened even in
counties where there was little or no AIDS. In Namibia, for instance, the
sibling method detected a 156 percent rise in the fourteen years prior to
1992, when the country's HIV infection rate ranged from zero to one
percent. "This lack of precision," Hill and his associate wrote,
"precludes the use of these data for trend analysis."
"I disagree," said Timaeus, who believes they got their math wrong.
Neither Hill or any members of his team wanted to respond on the record,
but I drew one of them into a conversation on another subject.
"Do you accept the high levels of HIV infection being reported by
Geneva?" I asked.
"I don't have much faith," he said. "It's essentially a modeling
exercise, and the exercise has always seemed to have a political
dimension."
That rung a bell. I was living in Los Angeles in 1981, when the very
first cases of GRID were detected. I knew men who were stricken, and I
sympathized entirely with their desperation. They wanted government action
and knew there would be little as long as the disease was seen as a
scourge of queers, junkies and Haitians. So they forged an alliance with
powerful figures in science and the media and set forth to change
perceptions, armed inter alia with potent slogans such as "AIDS is
an equal-opportunity killer" and "AIDS threatens everyone." Madonna, Liz
Taylor and other stars were recruited to drive home the message to the
straight masses: AIDS is coming after you, too.
These warnings were backed backed up by estimates such as the one
issued by the CDC in 1985, stating that 1.5 million Americans were already
HIV-infected, and the disease was spreading rapidly. Dr Anthony Fauci, now
head of the National Institute of Allergic and Infectious diseases,
prophesied that "2 to 3 million Americans would be HIV-positive within a
decade. Newsweek's figures in a 1986 article were at least twice as
high. That same year, Oprah Winfrey told the nation that "by 1990 one in
five" heterosexuals would be dead of AIDS. As the hysteria intensified,
challenging such certainties came to be dangerous. In 1988 New York City
Health Commissioner Stephen C. Joseph reviewed the city's estimate of HIV
infections, concluded that the number was inaccurate and halved it, from
400,000 to 200,000. His office was invaded by protesters, his life
threatened. Demonstrators tailed him to meetings, chanting, "Resign,
resign!"
In hindsight, Dr. Joseph's reduced figure of 200,000 might itself be an
exaggeration, given that New York City has recorded a total of around
120,000 AIDS cases since the start of the epidemic two decades ago. In
1997, a federal health official told the Washington Post that by
his calculation, the true number of HIV infections in the United States
back in the mid-Eighties must have been around 450,000 - less than
one-third of the figure put forth at the time by the CDC.
If the numbers could be gotten so wrong in America, what are we to make
of the infinitely more dire death spells cast upon the developing world?
In 1993, Laurie Garrett wrote in her book The Coming Plague that
Thailand's AIDS epidemic was "moving at super-sonic speed." It has stalled
at just below two percent, according to UNAIDS. In 1991 All India
Institute of Medical Sciences official Vulmiri Ramalingaswami said AIDS in
India "was sitting on top of a volcano," but infection levels there have
yet to crest one percent. The only place where the AIDS apocalypse has
materialized in its full and ghastly glory is in Geneva's computer models
of the African pandemic, which show millions dead and far worse coming.
Why Africa, and Africa only? I now know a possible reason. Read on.
"Crap!" An Expert Declares
In many ways, the story of AIDS in Africa is a story of the gulf
between rich and poor, the privileged and the wretched. Here is one way of
calibrating the abyss.
Let's say you live in America, and you committed an indiscretion with
drugs and needles or unprotected sex a few years back, and now find
yourself plagued by ominous maladies that won't go away. Your doctor
frowns and says you should have an AIDS test. She draws a blood sample and
sends it to a laboratory, where it is subjected to an exploratory ELISA
(enzyme-linked immunosorbent assay) test. The ELISA cannot detect the
virus itself, only the antibodies that mark its presence. If your blood
contains such antibodies, the test will "light up," or change color,
whereupon the lab tech will repeat the experiment. If the second ELISA
lights up, too, he'll do a confirmatory test using the more sophisticated
and expensive Western Blot method. And if that confirms the infection, the
Centers for Disease Control recommends that the entire procedure be
repeated using a new blood sample, to put the outcome beyond all doubt.
In other words, we're talking six tests in all, doubly confirmed. Such
a protocol is probably foolproof, but as you draw away from the First
World, health-care standards decline and people grow poorer, meaning that
confirmatory tests become prohibitively expensive. In Johannesburg, for
instance, a doctor in private practice will typically want three
consecutive positive ELISAs before deciding that you are HIV-positive. But
his counterpart in a government-sponsored testing center has to settle for
two ELISA tests.
In the annual pregnancy-clinic surveys on which South Africa's
terrifying AIDS statistics are based, the protocol is one ELISA only,
unconfirmed by anything. In America one ELISA means almost nothing.
"Persons are positive only when they are repeatedly reactive by ELISA and
confirmed by Western Blot," says the CDC. The companies that manufacture
ELISAs agree: The tests must be confirmed by other means. "Repeatedly
reactive specimens may contain antibodies" to HIV, one firm's literature
says, "Therefore additional, more specific tests must be run to verify a
positive result."
In parts of Africa, however, at least for the pupose of data-gathering,
such precautions are deemed unnecessary. That's partly because the World
Health Organization itself actually evalutates commercial HIV tests as
they come on the market. In these trials, new tests are measured against a
panel of several hundred blood samples from all over the world. Some of
the samples are HIV-positive, some are not. The ELISAs are tested to make
sure they can tell which are which. Among the scores of brands evaluated
throughout the years, a handful have proved to be useless. But those
manufactured by established biotechnology corporations usually pass with
flying colors, typically scoring accuracy rates close to perfect.
In South Africa, such outcomes were often cited in furious attacks on
President Mbeki. "HIV tests such as the latest-generation ELISA are now
more than ninety-nine percent accurate." reported the Weekly Mail and
Guardian. The tests have confidence levels of 99.9 percent, said
professor Malegapuru Makoba, head of the Medical Research Council. Science
had spoken, and science was unanimous: The tests were fine, and Mbeki was
a fool, according to the Weekly Mail, "trying to be a Boy's Own
basement lab hero of AIDS science."
It was a good line. I laughed, too, but there came a moment when it
ceased to be funny.
My education in the complexities of the ELISA test started when I came
across an article in a scientific journal published last year. It told a
story that began in 1994, when researchers ran HIV tests on 184 high-risk
subjects in a South African mining camp. Twenty-one of the subjects came
up positive or borderline positive on at least one ELISA. But the results
were confusing: A locally manufactured test indicated seven, but different
people in almost every case. A French test declared fourteen were
infected.
It seemed something was confounding the tests, and the prime suspect
was plasmodium falciparum, one of the parasites that causes
malaria: Of the twenty-one subjects who tested positive, sixteen had had
recent malaria infections and huge levels of antibody in their veins. The
researchers tried an experiment: They formulated a preparation that
absorbed the malaria antibodies, treated the blood samples with it, then
retested them. Eighty percent of the suspected HIV infections vanished.
The researchers themselves admitted that these findings were
inconclusive. Still, considering that Africa is home to an estimated
ninety percent of the world's malaria cases, the implications of the
report seemed intriguing. I asked Dr. Luc Noel, the WHO's
blood-transfusion-safety chief, for his opinion. He insisted there was no
cause for concern. Then he handed me a booklet detailing the outcome of
the WHO's evaluation of commercial ELISA assays. In it, I found two of the
three tests that had been used in South America - the very ones that
supposedly went haywire, kits manufactured in Britain and France,
respectively. One was rated By WHO as ninety-seven percent accurate, the
other, ninety-eight percent.
On the other hand, I couldn't help noticing that according to the
literature Noel had given me, the disease police apply at least five
confirmatory tests to every blood sample before such high accuracy rates
are achieved. What happens if you use just two, or one? And if your
subjects are Africans whose immune systems are often, as UNAIDS head Peter
Piot once phrased it, "in a chronically activated state associated with
chronic viral and parasitic exposure." There may be an answer of sorts.
The Uganda Virus Research Institute is possibly Africa's greatest
citadel of HIV studies. Seated on a hilltop overlooking Lake Victoria and
generously funded by the British government, the UVRI employs around 200
scientists and support personnel, runs an array of advanced AIDS studies,
tests experimental drugs, labors to produce an AIDS vaccine and has
generated scores of scientific papers during the past decade.
In 1999, the Institute screened thousands of blood samples using ELISA
tests that has achieved excellent results in a WHO evaluation. Test-driven
in a lab in Antwerp, Belgium, one test scored 99.1 percent accuracy, while
the other achieved a perfect 100. But in the field, in Africa, it was
another story entirely. There, exactly 3,369 samples came up positive on
one ELISA, but only 2,237 of those (66 percent) remained positive after
confirmatory testing. In other words: a third of Ugandans who tested
positive on at least one of these supposedly near-perfect ELISAs were not
carrying the virus. What does this say about countries where AIDS
statistics are based on a single ELISA? A high-ranking source at UVRI -
one who insisted on anonymity - said that the WHO estimates for AIDS in
such countries "could be as much as one-third higher than they actually
are."
I took this up with Dr. Neff Walker, a senior adviser at UNAIDS, who at
first seemed puzzled. "The standard WHO/UNAIDS protocol calls for two
tests in countries with a higher prevalence," he said.
But according to a WHO report, "Confirmation by a second test is
necessary only in settings where estimated HIV prevalence is known to be
less than ten percent." This means that in countries like mine, estimates
are based on one unconfirmed test.
Dr. Walker conceded that, but said it wasn't particularly important
given that most African counties have what he called "quality assurance"
programs in place.
"I feel," he said, "that if a government found any evidence of too many
false positives in their testing, they would report it. Governments would
like to find evidence of a lower prevalence, as would we all, and since
they have the data to easily check your hypothesis, they would do so and
report it."
But would they? High AIDS numbers are not entirely undesirable in
poverty-stricken African countries. High numbers mean deepening crisis,
and crisis typically generates cash. The results are now manifest:
planeloads of safari scientists flying in to oversee research projects or
cutting-edge interventions, and bringing with them huge inflows of foreign
currency - about $1 billion a year in AIDS-related funding, and most of it
destined for the countries with the highest numbers of infected citizens.
On the ground, these dollars translate into patronage for politicians
and good jobs for their struggling constituents. In Uganda, an AIDS
councelor earns twenty times more than a schoolteacher. In Tanzania. AIDS
doctors can increase their income just by saving the hard-currency per
diums they earn while attending international conferences. Here in South
Africa, entrepreneurs are piling into the AIDS business at an astonishing
rate, setting up consultancies, selling herbal immune boosters and vitamin
supplements, devising new insurance products, distributing condoms,
staging benefits, forming theater troupes that take the AIDS prevention
message into schools. A friend of mine is co-producing a slew of TV
documentaries about AIDS, all for foreign markets. Another friend has got
his fingers crossed, since his agency is on the shortlist to land a $6
million safe-sex ad campaign.
Sometimes it seemed I was the only one in South Africa who found this
odd. Dr. Ed Rybicki, a University of Cape Town microbiologist, caught
sight of part of this article while it was being prepared and found it
alarming. "Vast inflation of HIV figures by bad tests?" he wrote in an
email. "Naaaaah. The test manufacturers have done a hell of a lot
of research, which is not published because it is part of quality control,
rather than part of a global cartel conspiracy to make Africans
HIV-positive!" He allowed that there was "probably some truth" in stories
about "various factors confusing the HIV test" but accused me of stringing
them together in an irresponsible way. "Crap!" he ultimately declared.
"Utter garbage."
I defer to Dr. Rybicki in matters of science, but his denunciation
rested on the flawed assumption that, as he wrote to me, "In South Africa,
tests are repeated, and repeat positives are confirmed by another method,
meaning there is a threefold redundancy." Maybe that's how it works in
universities or research labs. But when it comes to UNAIDS statistics, one
test is evidently enough.
Can You Wait Ten Years?
And so we return to where we started, standing over a coffin under a
bleak Soweto sky, making a clumsy speech about a sad and premature death.
Adelaide Ntsele died of AIDS, but the word didn't appear on her death
certificate. Here in Africa, those little letters stigmatize, so doctors
usually put down something gentler to spare the family further pain. In
Adelaide's case, they wrote TB. But her sister Elizabeth had no such need
of such false consolation. She donned a red-ribbon baseball cap and
appeared on national TV, telling the truth: "My sister had HIV/AIDS." As a
nurse, Elizabeth had no qualms with the doctors' diagnosis, and she
concurred with their decision to forgo surgery and let Adelaide die. "It
was God's will," she says, and she was at peace with it. I was the one
beset by all the doubts.
Did Adelaide really die of AIDS? It certainly looked that way, but she
also had TB, the second-most-frightening disease in the world today, on
the rise everywhere, even in rich countries, sometimes in a virulent
drug-resistant form that kills half its victims, according to the CIA's
recent report on infectious disease. Eight years ago, the WHO declared
resurgent TB a "global emergency," but the contagion continues to spread,
particularly in the cluster of southern African countries simultaneously
stricken by the worst TB and HIV epidemics on the planet. It takes a blood
test to establish the underlying presence of an HIV infection in people
with TB, and at least one scientist who knows about these things has
imputed that the tests might not be entirely reliable.
Back in 1994, Max Essex, head of the Harvard AIDS Institute, and some
collegues of his observed a "very high" (sixty-three percent) rate of
ELISA false positives among lepers in central Africa. Mystified, they
probed deeper and pinpointed the cause: two cross-reacting antigens, one
of which, lipoarabinomannan, or LAM, also occurs in the organism
that causes TB. This prompted Essex and his collaborators to warn that
ELISA results should be "interpreted with caution" in areas where HIV and
TB were co-endemic. Indeed, they speculated that existing antibody tests
"may not be sufficient for HIV diagnosis" in settings where TB and related
diseases are commonplace.
Essex was not alone in warning us that antibody tests can be confused
by diseases and conditions having nothing to do with HIV and AIDS. An
article in the Journal of the American Medical Association in 1996
said that "false-positive results can be caused by nonspecific reactions
in persons with immunologic disturbances (e.g., systemic lupus
erythematosus or rheumatiod arthritis), multiple transfusions or recent
influenza or rabies vaccination.... To prevent the serious consequensces
of a false-positive diagnosis of HIV infection, confirmation of positive
ELISA results is necessary.... In practice, false-positive diagnoses can
result form contaminated or mislabeled specimens, cross-reacting
antibodies, failure to perform confirmatory tests.... or misunderstanding
of reported results by clinicians or patients." These are not the only
factors that can cause false positives. How about pregnancy? The U.S.
National Institutes of Health states that multiple pregnancy can confuse
HIV tests. In the past few years, similar claims have been made for
measles, dengue fever, Ebola, Marburg and malaria (again).
But let's put all that science aside, for a moment. Lots of people
thoght it was wrong for me even to pose questions such as these,
especially at a moment when rich countries, rich corporations and rich men
were considering billion-dollar contributions to a Global AIDS Superfund.
They were brought to this point by a ceaseless barrage of stories and
images of unbearable suffering in Africa, all buttressed by Geneva's death
projections. Casting doubt on those estimates was tantamount to murder, or
so said Dr, Rybicki, the Cape Town microbiologist.
"AIDS is real, and is killing Africans in very large numbers," he
wrote. "Presenting arguments that purport to show otherwise in the popular
press is simply going to compound the damage already done by Mbeki. And a
lot more people may die who may not have otherwise."
Rybicki was right. But what are the facts? After a year of looking, I
still can't say for sure.
When I embarked on this story, you may recall, no massive rise in
registered deaths was discernable in South Africa. A year later, I decided
to return to my point of departure to see if the discrepancy persisted. I
wrote to the country's Department of Home Affairs,which manages the death
register, and asked for the latest numbers. In response came a set of
figures somewhat different from those initially provided - the
consequence, I am told of people who died without any identity documents.
Here is the final analysis:
Deaths registered in 1996 - 363,238.
Deaths registered in 200 - 457,335.
As you see, registered deaths have indeed risen - not to the
extent prophesied by the United Nations, perhaps, but there is definite
movement in an ominous direction. Deaths are up across the board, but
concentrated in certain critical age groups: females in their twenties,
and males age thirty to thirty-nine.
A team of experts commissioned by the Medical Research Council has
studied this changing death pattern and found it to be "largely consistent
with the pattern predicted by [ours] and other models of the AIDS
epidemic." Their conclusion: AIDS has become the "biggest cause" of
mortality in South Africa, responsible for forty percent of adult deaths.
And yet, and yet, and yet, even this is no the end of our tale, because
another governmental body, Stats SA, has challenged these findings. The
Washington Post reported that the South African census bureau called
the MRC study "badly flawed," saying "the samples were not representative,
and assumptions about the probability of the transmission of the virus
that causes AIDS were not necessarily accurate."
And that's my story: enigma upon enigma, riddle leading to riddle, and
no reprieve from doubt. Local actuarial models say 352,000 South Africans
have died from AIDS since the epidemic began. The MRC says 517,000. The
figure from a group I haven't even mentioned yet, the United Nations
Population Division, is double that - 1.06 million - and the unofficial
WHO/UNAIDS projections are even higher. I have wasted a year of my time
and thousands of Rolling Stone's editorial-budget dollars, and all
I can really tell you is that my faith in science has been dented. These
guys can't agree on anything.
Ordinary Africans everywhere see that the scourge is moving among them.
The guide who showed me around Uganda had lost two siblings. Our driver
had lost three. On the banks of the Kagera River, where the plague began,
we met a sad old man who said all five of his children had died of it.
But ask these people about access to health care, and they laugh
ruefully. "The coffee price is collapsing," they say. No one has money. We
can't even afford transport to hospital, let alone medicine." All across
rural east Africa, doctors confirmed the charge: no money, no medicine.
Even mission hospitals now ask patients for money.
"What can we do?" asks Father Boniface Kaayabula, who works at a
Catholic mission in rural Uganda. "We have no money, too. We must ask
people to pay, and only a very few can."
So what do poor Africans do if they fall sick? They go to roadside
shacks called "drug stores" and buy snake oil. Chloroquine for malaria, on
a continent where that former miracle drug has lost most of its curative
power; nameless black-market antibiotics for lung diseases, in a setting
where up to sixty percent of pneumonia is drug-resistant; penicillin for
gonorrhea, administered by an amateur "injectionist" who might be unaware
that the quantity needed to knock out the infection has risen a
hundredfold in the past decade. For the poorest of the poor, even such
dubious nostrums are beyond reach. They try to cure themselves with herbs,
they fail, and they die.
What's to be done? Dr. Joseph Sonnabend is a South Africa-born
physician who was running a venereal-disease clinic in New York back in
the early Eighties, when GRID first appeared. He became known throughout
the world as a pioneer in AIDS treatment. When President Mbeki launched
his controversial inquiry into the disease last year, Sonnabend came home
to participate, an experience he likens to "entering hell."
As founder of the AIDS Medical Foundation, which became the American
AIDS Research Foundation, or AmFAR, Sonnabend has no patience with those
dissidents who dispute the syndrome's existance or HIV's power to cause
it. But he also believes there are "opportunists" and "phonies" whose
chief skill is "manipulation of fear for advancement in terms of money and
power." In fact, he quit AmFAR, his own group, because he felt it was
exaggerating the threat of a heterosexual epidemic. A decade later, he's
still fighting the lonely battle for wise policies, especially in Africa.
In Pretoria, he says, one faction argued for the bulk of available
funds to be committed to the purchase of AIDS drugs. But merely dumping
AIDS drugs into resource-poor countries is pointless, Sonnabend argued,
although he does believe there are limited situations where they could be
safely and effectively used. The prevention of mother-to-child
transmission is one; another is in people with advanced disease where
facilities to adequately monitor the use of drugs are in place.
Unfortunatly, the cost of establishing an infrastructure to do this on a
large scale would be enormous, and without this hardly anyone would
benefit, save drug manufacturers.
The answer, he feels, is to eliminate conditions that render Africans
vulnerable to HIV in the first place. A year down the line, Sonnabend is
still trying to organize an international conference to discuss the
disposition of the money lodged in the Global AIDS Superfund. The way he
sees it, $1 billion a year would be enough to transform the lives of
ordinary Africans and curb the AIDS epidemic, but only if it's not
squandered on unsustainable "drugs into people" programs.
"There's a place for AIDS drugs and prevention campaigns," he says,
"but it's not the only answer. We need to roll out clean water and proper
sanitation. Do something about nutrition. Put in some basic health
infrastructure. Develop effective drugs for malaria and TB and get them to
everyone who needs them."
On the other hand, we have researchers like the ones from Harvard
University who insist that biomedical intervetion is morally inescapeable.
"We can raise people from their deathbeds," said professor Bruce Walker.
They calculated that it should be possible to provide Africans with AIDS
drugs for as little as $1,100 a year.
Granted, says Sonnabend, but this makes little sense if that one lucky
person's neighbors are dying for lack of medicines that cost a few cents.
So who's right? Depends on the numbers, I guess. In the end, I
attempted to bring all my unanswered questions on that topic to the man
who was there when the epidemic first hit this continent, Dr. Peter Piot,
who has today risen to the role of chief of UNAIDS.
But my call to him was directed instead to UNAIDS' chief
epidemiologist, a physician named Dr. Bernhard Schwartlander.
The UNAIDS computer model of Africa's epidemic is in fact completely
dependable, Dr. Schwartlander says because it relies on a "very simple
formula. You take the median survival time - around nine years in Africa.
You say this is roughly the distribution curve. Calculation of deaths is
completly plausable if - and this is important - you have a good idea of
the prevalence of HIV and how it spreads over time."
Why then, I asked, do we have so many different estimates of AIDS
deaths in South Africa?
"I'm not shocked," he said. "The models may completely disagree at a
particular point in time, but in the end the curves look incredibly
similar. They're goddamn consistant."
If that's true, I said, then why would we have 457,000 registered
deaths here last year when the UN says 400,000 of them died of AIDS? One
of those numbers must be wrong.
"You say there are 457,000 registered deaths in South Africa?"
Schwartlander said, momentarily nonplussed. "This is an estimate based on
projections."
No, said I, it's the actual number of registered deaths last year.
"We don't really know," he replied. "Things are moving very fast. What
is the total number of people who actually die? For all we know, it could
be much higher. HIV has never existed in mankind before, and there's no
anchor point set in stone." The UNAIDS numbers are, after all, only
estimates. We are not saying this is the number. We are saying this
is our best estimate.Ten years from now, we won't have these problems. Ten
years from now, we'll know everything."
Ten years! Had I known, I could have saved myself a lot of grief. For
even as I tried to track down the old numbers, bigger new ones were
supplanting them - 17 million Africans dead of AIDS and 25 million more
with HIV, UNAIDS now estimates; not one in five South African adults
infected but one in four. Are these numbers right? Who knows. Feel free to
publish this, Jann, but if it drives you as mad as it has driven me, I'll
understand.
Yours,
Malan
Rian Malan is the author of "My Traitor's Heart: A South African
Exile Returns to Face His Country, His Tribe and His Conscience."
