Continent's educated can no longer run things: They're dead or can't cope
By STEPHANIE NOLEN, The Globe and Mail
NKHOTAKOTA, MALAWI -- The Grade 5 class at Mphunga Primary School has 117 students and one teacher. The pupils who are not crammed on benches must find a perch on a windowsill or on the dusty concrete floor. But the problem is not lack of space.
At this school in central Malawi, like thousands across the impoverished country, there are not enough teachers. Mphunga Primary is down in staff by a third.
At the police headquarters, long corridors of offices are empty. At the government hospital, the reed-thin bodies of the sick are crammed four to a bed, with no mattresses, and lined up along the floor. For the 1,000 patients, all desperately ill, there is only one doctor and one nurse. The rest of the staff have died.
Once considered a disease of the poor and ill-informed, AIDS is now devouring the educated of sub-Saharan Africa, devastating even those nations that were success stories a decade ago. Doctors, nurses, teachers, civil servants, academics, police and army officers -- all are dying in greater proportion than any other group.
Countries such as Malawi are losing the people who are most needed to help battle the disease, and governments are starting to crumple under the impact.
"There is no sector of the economy that is not affected," said Biswick Mwale, a doctor and former hospital administrator who now runs Malawi's National AIDS Commission. "The government spends frantically, training people for jobs, and they stay one year and then they are dead."
While almost everyone views Africa's AIDS pandemic as a human tragedy, its manifestation as an economic and political crisis is just now being understood. For leaders of the Group of Eight industrialized countries, meeting next week in Kananaskis, Alta., the pandemic threatens to be the most challenging issue on their agenda for a new Africa.
Yet in discussions over the past year about a rescue plan for Africa, HIV/AIDS has taken a back seat to talk of trade, investment and good government. Five influential African leaders, led by South Africa's Thabo Mbeki and Nigeria's Olesegun Obasanjo, will lobby the G8 for a massive infusion of aid, pledging democratic reform across the continent. Yet with just one week to go before the summit, critics say the proposed covenant for change -- the New Partnership for African Development, or NEPAD -- has overlooked what is by far the most critical element.
"There is only one paragraph in NEPAD about AIDS," noted Stephen Lewis, special adviser on HIV/AIDS to United Nations Secretary General Kofi Annan. "The document is genuinely flawed by the kind of superficial way it deals with the pandemic. It's crazy to talk about $64-billion [U.S.] in aid, and the economic regeneration of African economies, if you're not dealing with what the pandemic will do down the road, with what it's doing now."
Malawi has vast skies and jutting hills, but the view at ground level is apocalyptic. This country trails South Africa and Botswana in infection rates, with an overall HIV/AIDS prevalency estimated at 17 per cent. But that is enough to have lowered the national life expectancy to 39 years, from 48 years in the mid-1990s.
Since the first case here was diagnosed in 1985, health officials estimate that 500,000 have died from the disease, in a nation of only 11 million. At least 600,000 children have been orphaned.
But in the most economically productive age group, those between 15 and 35, Malawi faces carnage worse than war. One-quarter of its youths and young adults are thought to be infected. Studies in urban chronic-care wards suggest the infection rate among educated, middle-class people is as high as 50 per cent.
"It has set us back 20 years," said Malawi's Vice-President, Justin Malewezi.
The secondary-school system is already short 8,000 teachers, largely because of AIDS-related deaths and long-term absences. Malawi is losing about 10 per cent of its doctors every year. At the central bank, only a handful of senior policy workers are left.
The disease has also inflicted an extraordinary rate of absenteeism on the economy. Funerals and nursing the sick are now a part of daily life. AIDS has dealt a blow to the national rate of savings, with people devoting a huge portion of their income to health care and treatment.
In such an environment, traditional development strategies are rendered useless. "Normal methods don't work," said Paul Ginies, the European Community's food-security adviser in Malawi.
"How can we do microcredit, for example? Nobody will give loans when they know people are going to die before they can ever repay them. Who is going to come here and open a factory, when you know that you train a work force and most of them will be dead in four years?"
In the towns and cities, the most puzzling question is: Why are the best-educated people dying of a disease that is, by African standards of malaria, typhoid and hepatitis, easily prevented?
One reason is the relatively enormous economic power educated professionals enjoy in poor nations, and how that power can be multiplied when it is held by a man in a society that affords women few rights.
Though he may earn only $100 a month, for instance, a man with a good civil-service job can afford to buy sex regularly from prostitutes. His income and status also allow him to woo both a wife and several girlfriends on the side, a modern variation on traditional polygamy.
In schools, teachers' elevated status gives them sexual access to students, making teachers what is known as a vector for the disease, carrying the infection from one person to another.
"AIDS is co-related with wealth," Dr. Mwale said frankly. "Those with buying power have the power to buy sex."
It is still common for village girls to be initiated into sex by a male neighbour when they are 10 years old, yet efforts at AIDS education here must be tailored to the confines of a puritanical morality espoused by government and influential churches. (Two weeks ago, the government ordered an advocacy group to withdraw condom ads depicting a woman in a thigh-baring slit skirt, saying it was immoral and inappropriate.)
"The religions preach abstinence and be faithful, but the Christians are dying, the church leaders are dying," Dr. Mwale said.
Added to this is the widespread belief here, as in neighbouring countries, that having sex with a virgin girl can cure a man infected with AIDS, a practice responsible for the rapid spread of new infections.
The denial can be found well beyond the pulpit, from government offices to villages, where people insist that someone who died of AIDS was bewitched by a jealous neighbour.
Ellen Kacapa, a police officer in Lilongwe, lost her husband, two sisters, two uncles and a niece to AIDS in the past two years. She had tuberculosis last year, and suffers from chronic diarrhea, two infections commonly linked with AIDS in Africa; last winter she was finally tested.
"They told me I was positive, but I don't believe them," said the 43-year-old, who is supporting her six children and five orphans. "I feel fine. It's a nasty rumour to discredit me."
Hobbled by denial, stigma and secrecy -- problems common across sub-Saharan Africa -- Malawi is nonetheless mustering its limited resources to fight the disease.
Through the Global Fund to Fight AIDS, Tuberculosis and Malaria (a multilateral initiative seeking to generate massive new funding for the three killer diseases), the government expects to receive as much as $23-million this year. Canada has also pledged $15-million over five years to Malawi's National AIDS Commission, which is independent of the government.
It's going to take more than millions. "It has destroyed the health system," said Dr. Mwale of the AIDS commission. "In the mid-'80s, we had 5,000 cases a year of TB. We were winning the war with the new drugs. But 25,000 cases of TB were reported last year." Tuberculosis is one of the most common infections for Africans with HIV.
Sixty per cent of Malawi's hospital admissions are HIV-related, he said, but patients with the classic signs of AIDS aren't even tested, not when each test costs $1.50, and the country has only $6 in its annual health-care budget for each Malawian.
Even if the hospitals had staff and basic drugs, there is little they could do for most people who have progressed to all-out AIDS. So the government is putting new emphasis on home-based care: training family members and volunteers to nurse the dying, to dress their sores and rehydrate those weakened by the chronic diarrhea.
In Nkhotakhota, 300 kilometres north of the capital on Lake Malawi, the local AIDS Support Organization (known as NASO) struggles to serve 212,000 people in the district, on an annual budget of $200,000.
NASO has trained volunteer counsellors to teach people with HIV about nutrition and stress management, so they can live as long as possible; about wills, so distant relatives don't seize their property when they die; and about prevention, so they do not spread the disease.
The volunteers counsel people who decide to get an HIV test. They run a daycare for orphans. They help parents with the disease create "memory books," so their young children will have some way to know them after they die.
NASO also trains residents to ease AIDS patients through the long, painful and irreversible decline that the disease brings to poor lives. Their humble handbook teaches home care with zero resources: Place newspapers beneath the the incontinent. Use juice from frangipani flowers to ease the pain of oral thrush. Treat herpes infections with yogurt.
A few skilled volunteers are trained to dispense paracetemol (the generic name for Tylenol), the only drug NASO has to offer pain-riddled patients.
Lillian Chandawili has learned from NASO about eating fresh vegetables, and the group sometimes sends someone to chop her wood and pound her maize. But it can't solve the problem that consumes her.
Ms. Chandawili has AIDS, and she has nine children: five of her own, plus two orphans left by her sister and two young cousins she took in after their parents died of the disease. Her husband left a decade ago.
Ms. Chandawili is tired all the time these days, from the coughing and the constant diarrhea. She knows what this means: The end is coming. And she is racked with worry about the children. All of her siblings are dead, from AIDS. Her two surviving aunts already have a house full of orphans. The adults in the house next door are dead. And the neighbours on the other side have more children to care for than they can feed.
"When I think who will look after the children -- all the ones I thought would do it, they have passed away," Ms. Chandawili said, resting her sore, thin limbs on the cement front step of her thatched-roof house. "I am the one left behind. Now I have no idea who will care for them."
Malawi hopes soon to have greater access to the one known thing that could check the destruction AIDS is wreaking on Ms. Chandawili's life: drugs. Antiretroviral drugs (ARVs) have transformed the lives of AIDS patients in developed countries, but bringing them to Africa is proving as contentious as every other aspect of the disease.
The cost of providing antiretroviral drugs to all HIV-positive people in Malawi is estimated to be as much as $11-billion for the first year. Many health experts, including the Canadian Public Health Association, believe the money would be better spent on other causes, such as sex education, distributing condoms and developing public-health care.
Even if the drugs were available, those experts say, Malawi's hospitals and clinics would not be able to distribute them, or monitor compliance, or do the laboratory tests on which their use depends. If there is limited money, who should get the drugs first? Teachers and civil servants? Mothers with several dependents? Or the poorest of the poor, who need to be in their fields every day to survive?
The government believes its critics are missing the bigger point, that ARVs would save Malawi billions of dollars in the long term. The drugs would keep parents alive to care for their children; keep the teachers, doctors and civil servants alive; and dramatically reduce the cost of treating secondary infections, such as TB.
"You can oppose it [the use of ARVs] from a clinical point of view, but if you go and stare death in the face, you have to talk about care and support for people who are already infected," said Erasmus Morah, an Edmonton development expert who heads the UN's AIDS organization in Malawi.
In the thatched huts around Nkhotakhota, however, the debate seems cruelly academic for people like Ms. Chandawili. As the clock ticks against her, she cannot think about foreign-made drugs, which cost about $50 a month on the private market. She has those nine children to feed and house. And everywhere she turns for help, from the clinic or the school or the government office, there seems to be one less person than before to help her.
Ms. Chandawili worries about the food she cannot harvest and the school fees she cannot pay. She worries about who will worry, when she is dead. There are men and women like her all over sub-Saharan Africa, whose limited energy and even more limited resources go into just surviving.
Next week, when the G8 looks at Africa, the rest of the world will have a chance to look at the bigger picture. There will be much talk about the continent's wars, its corrupt governments and its disastrous economic policies, which keep it mired in poverty. And there will be just as much talk about the great hope that peace, trade, investment and better management can bring to the world's poorest continent.
But to assess any of these, and decide what role the North should play in Africa's future, the leaders of the world's richest nations must grapple with the impact of AIDS as never before. First and last, it has become the dominant force in African development. The reality of AIDS means that nothing short of a new approach to Africa will work.
A new generation of African leaders says it is willing to make drastic changes in the approach to development. Western leaders have indicated they're willing to co-operate.
But if their actions are to have any meaning for Lillian Chandawili -- and millions like her -- they will have to move fast.
Last of four parts.