Jeremy Laurance, Health Editor, The Independent, London conducted a regional workshop in Blantyre, Malawi, 9 to 13 February 2003.
'Malawi - The Aids Nightmare'
By Jeremy Laurance
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Photo: Christian Aid / Tom Pilston |
There were six pages of Valentine tributes in The Nation newspaper,
Malawi's largest selling daily, last weekend. The messages, each topped by
a heart shaped photo of the intended, had a beguiling innocence about them.
There was no innuendo, no suggestiveness, no lovey-dovey language - just
straightforward declarations from the heart. "Your love gives me courage",
Phiri told her boyfriend George Mphasa. "Your love makes me a better man,"
Henry promised his girl, Grenna Kaiya.
So romance can flower even in a land where it has brought so much death
and suffering. Everyone knows that out of the desire that drives men and
women together has come a disease which is destroying Africa. One in three
of the lovers who pledged their loyalty to their partners in the pages of
The Nation will be infected with HIV - and an untold number will, despite
the risks, break their vows of loyalty and have sex with someone else.
On Monday, the UK chancellor Gordon Brown warned that progress towards
development in some parts of the world was so slow it could take more than
a century to achieve the millennium goals set for 2015, which include a
target of halting the spread of AIDS. But AIDS cannot be defeated by money,
or medical research or international help alone. The battle against AIDS
will depend also on achieving social and cultural change - and that could
be the toughest challenge of all.
The young urban Malawians who placed their Valentine messages in the
papers are no different from young people everywhere. They like to go out
and drink and dance and flirt with the opposite sex. At the Panorama bar,
newly built on a hill a few miles outside Blantyre, the band was belting
out old rock standards last Friday night and scores of young people were
shaking their booty on the open air dance floor in the warm African night.
George, a large man with a big laugh, returned from the dance floor for
another beer. "I am going back," he announced, with a grin, "I am getting
lots of offers."
Girls with spray-on trousers and plunging necklines eyed the men,
approaching strangers as if they were old friends. A bar girl came over to
take our order and sat down with her thigh pressed against mine. When I
asked, prosaically, where the toilets were, she offered to show me, telling
my companions in Chichewe, the local language, "I think I am doing well
with him."
Peter, a tall serious man from Tanzania, described how he took his sister
to a bar in Dar es Salaam and was given a very frosty reception by the bar
girls. "They don't like it if you go there with someone," he said. "They
regard every man as a potential client."
One of the tragedies of the Aids story is that while vast sums of money
have been poured into research aimed at finding a cure for the disease, far
less effort has been expended on understanding the social and cultural
forces that have fanned the flames of the epidemic. As Alex de Waal of
Justice Africa has noted, faith in medical science may have retarded
investment in humbler preventive technologies, such as finding inventive
ways of promoting the condom. Or, more importantly, improving the economic
and social position of women. Much more is known about the virological
complexities of the Aids virus than the sexual networks and practices that
help it to spread.
For 30 years until the early 1990s, Malawi was locked in a time warp under
its conservative president, Hastings Banda, who had a deep fear of the
modern world. Long hair for men was banned and women were forbidden from
wearing short skirts or trousers.
In the decade since Banda's death, many of the restrictions that were
strangling development have been loosened - but vestiges of the old
attitudes remain. Recently in Blantyre a skimpily dressed woman was set
upon by a mob, offended by her provocative attire, stripped naked and run
out of town. Her dignity was only saved by a friend who covered her with a
blanket.
Some preach abstinence and faithfulness as the only means to curb the Aids
epidemic in Africa - and there is some evidence that, combined with
promotion of condom use, this has had success in reducing infection rates
in Uganda. But the strategy ignores a key feature of the culture - the
economic dependence of women on men.
Women are taught from the earliest age to be subservient to men. In the
Panorama bar, the bar girls address their male customers as "Bwana" and
give a little curtsey as they are paid. Women are less likely to be
educated and less likely to find paid work. That gives men a licence to
misbehave and leaves women with no option but to consent to their demands.
As one 20 year old woman put it: "What are relationships about then? Men
are supposed to provide money and other things."
I was in Blantyre to run a course for local journalists on reporting
HIV/Aids, organised by the Commonwealth Press Union. While the 18
participants - 14 men and four women from across sub-Saharan Africa - were
keen to debate condom use, HIV testing and the provision of anti-retroviral
drugs, they were less comfortable with discussion of the relationship
between the sexes and the need to empower women.
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Malawi orphans |
The consequences of this failure are starkly evident. On Hanover street in
Blantyre, a woman approached George, a reporter from Zambia, outside a bar
and offered sex for 750 kwacha (£3.75). "Do you have a condom?" George
asked her (strictly in the interests of research, of course). She did, she
said, adding if he wanted "plain" sex - without a condom - the cost would
be double.
It is a small price for a big risk. But why should people care when life
is fraught with risk in any case? Malawi is a beautiful but benighted land.
Its warm hearted people are among the poorest in Africa and hunger and
disease are ever present threats. One in five children die before they are
five, the eighth highest childhood mortality in the world. Even today,
malaria claims more lives in Malawi than AIDS.
There is no security here, no welfare state, no guarantees for the
future. People live in the moment, for what they can get, because there is
no other way to live. The pleasure, or profit, from a moment's physical
intimacy now can seem worth the distantly perceived risk of a disease,
however deadly, in a year or two's time.
At the AIDS clinic at Thyolo hospital, a ramshackle collection of
buildings on a muddy hillside 30 kilometres south of Blantyre, run by
Medecins sans Frontiers, there were 900 men and 898 women tested for HIV in
December. Of these, 328 women were HIV positive compared with 206 men, a 60
per cent difference.
Women are twice as likely to be infected with HIV as men. But they cannot
refuse sex with their husbands or insist on condom use, even where the
husband has been proved to be HIV positive.
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Photo: David Scondras |
Rose Madengu, aged 20, a tall beautiful woman with huge dark eyes has
AIDS. The disease has left her long limbs skeletal - she weighs 34 kgs,
just over five stone. She was started on anti-retroviral drugs last
November - provided free by MSF - and compared to her condition then, she
is now much improved according to Dr Patrick Gomani, medical director.
Her mother, a plump, serene woman, sits with her daughter, an umbrella
propped between her legs. Rose explains how her two children died within
weeks of birth and her husband "ran away". She had suffered diarrhoea for a
year but now that has stopped - another sign that the drugs are working.
But the most important benefit the drugs have brought her is hope.
At last there is a point to getting tested for HIV - because now there is
a treatment. Since MSF began offering free treatment for Aids last April
the number coming for tests has steadily increased. And as testing becomes
more widespread, the stigma attached to the disease, and the behaviour with
which it is associated, diminishes.
A sign of the change came last week when President Bakili Muzuli launched
the Malawi Government's Aids policy which will see the nationwide provision
of antiretroviral drugs from next July. In doing so he made a plea for
openness about the disease - and revealed that his own brother had died of
AIDS.
As the drugs that have been denied for so long become available, for the
first time Malawians will learn that they may have a future after all -
and there may just be some point in changing the way they live to secure
it.
At the Moyo malnutrition clinic in Blantyre's Queen Elizabeth Hospital, 70
children were admitted last Tuesday of whom 35-40 per cent will be infected
with HIV. Although the country briefly made the international headlines in
2002 when a food crisis threatened a widespread famine, more children were
admitted to the Moyo clinic, and more died, in 2003 than in the previous
year. This year admissions are running high again - and about a third are
expected to die.
Mercy, 31, arrived at the clinic with her youngest child, a daughter aged
13 months weighing 3.9 kgs. That is equal to the birthweight of the average
baby in the West. She has left her five other children in the care of the
eldest, aged 15.
"I would love it if my baby were well and I could go back and find work to
support my family," she said.
She left her village to come to Blantyre to find work, met her husband and
married him. Now he has left her. To make money she carries sand from the
river for building houses - back breaking work for a thin and
under-nourished woman. She is slightly built with high cheek bones and the
solemn, steady, stoical gaze familiar across Africa. "I force myself to do
it. I have no choice," she says.
AIDS IN MALAWI
- Population 11.5 million
- 900,000 adults aged 15-49 are infected with HIV/AIDS
- One in four infected in urban areas and one in eight in rural areas
- 87,000 died from AIDS in 2003
- Teachers are dying at a faster rate than replacements can be trained
- 641,000 have died since the first case of AIDS was identified in 1985
- Target of 50,000 in treatment with anti-retroviral drugs by 2005
