New York Times

November 25, 2001, Sunday, Late Edition - Final
Correction Appended

SECTION: Section 1A;Page 1;Column 1;Foreign Desk

LENGTH: 2616 words

HEADLINE: South Africa's AIDS Vortex Engulfs a Rural Community

SERIES: DEATH AND DENIAL: A Constant Knell

BYLINE: By RACHEL L. SWARNS

DATELINE: HLABISA, South Africa

BODY:
The dusty road rolls past the builders hauling bricks from the Easi-Build Hardware store, past the women braiding hair at Ruby's Beauty Salon, past the butchers grinding beef at Isipho Supermarket, deep into the heart of rural South Africa.

Change has come slowly to this remote community in Zululand. But there are water pumps in the green hills. Black tar smooths stretches of the mostly gravel road. Electric lights glimmer in mud huts. At Gwegwede Primary School, giddy adolescents dream aloud in a country that no longer stifles black ambition. "Me, I'm going to be a doctor," says Patience Ntshangase, 12, her brown eyes flashing. "An engineer!" cries Bongumenzi Zwane, also 12.

President Thabo Mbeki has declared the 21st century to be Africa's century and says his country will help fuel the renaissance. Most Western leaders agree that if any country can make good on this continent's elusive promise, it will be South Africa, with its stable government, sizable economy and commitment to uplifting its people.

But Fanini Manqele, the principal at Gwegwede, no longer dreams such dreams. Two of his teachers, both young and promising, are dead.

Three more are ailing. In 1994, when blacks in this country voted for the first time, about 10 percent of adults in Hlabisa (pronounced shla-BEE-sa) were infected with H.I.V., the human immunodeficiency virus, which causes AIDS.

Today, the figure stands at about 35 percent, one of the highest rates in a nation that has more people infected with H.I.V. than any other country. Blinded by shame and denial, distracted by the enormous challenge of redressing racial inequities, black leaders have mostly closed their eyes to AIDS. Seven years after apartheid's demise, this community's young and productive people are dying, like many others across Africa. Not since the Black Death ravaged Europe in the 14th century has a continent confronted such a deadly disease.

The broad outlines of South Africa's epidemic are widely known: This nation of 44 million people has 4.7 million infected with H.I.V. What is less frequently explored is how ordinary communities are coping with a plague that is killing their citizens, threatening their culture and shattering their dreams.

President Mbeki has compounded the crisis by refusing to acknowledge the magnitude of the problem. He has stirred international furor by questioning whether H.I.V. causes AIDS and by challenging infection rates reported by his own government. He has been reluctant to subsidize AIDS treatment, citing the risk of side effects.

In October, Mr. Mbeki suggested that whites, and unwitting black allies, were deliberately overplaying the AIDS epidemic to undermine a black continent on the rise and to perpetuate stereotypes of Africans as "promiscuous carriers of germs."

Earlier this year, he ignited a firestorm by questioning whether AIDS is indeed the nation's biggest killer, as the government's leading medical institute contends. Casting doubt on that assertion, he cited six-year-old data from the World Health Organization that listed H.I.V. as 12th among 29 leading causes of death here.

His advisers say the world's largest drug companies are exaggerating the epidemic to expand markets for AIDS drugs. The companies deny those charges, but Mr. Mbeki has vowed to investigate the accuracy of H.I.V. statistics "that are regularly peddled as a true representation of what is happening in our country." His skepticism is unfathomable to many scientists and health officials, who say the statistics he cites are old.

Some critics suspect that Mr. Mbeki wants to avoid diverting scarce resources toward costly AIDS drugs, an expense so enormous that it might swallow the government's entire budget for drugs. Others believe that he cannot bear to admit that the nation's black government stood by while its supporters were dying. Mr. Mbeki, who is praised by Western leaders for his conservative economic policies and his vision for Africa, declined a request for an interview through his spokesman, Bheki Khumalo. In the past he has complained that his comments were misunderstood and he is reluctant to discuss the matter in public.

The Plague Marks a Town

Here in Hlabisa, in the desperately crowded clinics and hospital wards, the scale of the epidemic is clear enough. This district of 250,000 people sits amid the hills of KwaZulu Natal Province, which has the highest adult rate of H.I.V. infection of any province in South Africa, according to the government. It is one of the few communities in South Africa in which government researchers have kept statistics on H.I.V. infection rates for nearly a decade. Its story offers a rare and intimate look at one community ravaged by the plague.

The virus is invisible, people here say, but its fingerprints are everywhere.

It marks the faces of young widows who trudge the road in somber capes and skirts, traditional mourning garb. It inspires the medicine makers who brew slivers of tree bark and bundles of dried leaves into elixirs sold in used Coca-Cola bottles.

"Two spoons in the morning, two spoons in the afternoon," advises Elliott Mpungose, a herbalist who charges $1.25 a bottle.

It swamps the morgue where chilled bodies are often stacked one on top of another.

The virus also haunts the sandy courtyard of the Gwegwede School, where hundreds of students run with abandon, the boys in black ties and the girls in pleated skirts, their legs flying, their books swinging, oblivious to the health threat.

In 1994, the school had 21 teachers. Today it has 18. (One teacher left and was not replaced.) When the three sick ones die, says Mr. Manqele, the principal, they will make do with 15.

"We thought we were going to have changes and transformation, but we are dying in great numbers," the principal said as he awaited the death certificate for one of the teachers who died recently.

The Medical Research Council, the South African equivalent of the National Institutes of Health, believes that AIDS is now the leading cause of death in South Africa.

But even as scientists, doctors and church ministers ring the alarm bells, government officials continue to dither.

"We cannot afford any more blunders," Dr. Malegapuru Makgoba, president of the Medical Research Council and the government's leading scientist, warned in a speech earlier this year. "If, as Africans, we do not heed these examples and implications, history may judge us to have collaborated in the greatest genocide of all time."

In Hlabisa, the culture of denial has already taken its toll.

In the last decade, the number of patients admitted each year to the public hospital here has nearly doubled. Inadequate financing, a shortage of health professionals and inept management have left the hospital desperate for doctors and nurses.

Yet many local high schools still fail to offer AIDS education programs, even though statistics show that at least a quarter of young women under 20 here are infected. When government researchers surveyed 20 local schools, they found that more than a third lacked such programs.

Even with some AIDS education efforts, there is scant evidence to suggest that many people are changing their behavior. In a survey now under way here, only 26 percent of the 1,040 adults interviewed so far have reported ever using a condom, the Medical Research Council says.

The result reflected an improvement in a community where condoms are widely viewed as unmanly. In 1995, only 14 percent said they had ever used a condom.

Doctors and scientists here and abroad have condemned Mr. Mbeki for questioning the link between H.I.V. and AIDS last year, saying he left many South Africans to wonder whether they truly needed to use condoms or to change their behavior.

Stung by the criticism, Mr. Mbeki decided last year to stop discussing AIDS publicly. He also agreed to allow AIDS drugs to be distributed to pregnant women in public clinics for the first time, in a pilot program intended to reduce the risk of transmitting H.I.V. to newborns.

Mr. Mbeki, of course, did not create the problems he now faces. There is no doubt that the all-white apartheid government helped create the conditions that have fueled the spread of the disease by shattering stable families and forcing men to leave their families for work in faraway mines.

Suspicions about condoms also date back to the apartheid days, when the white government hired scientists in the 1980's to develop drugs to make blacks infertile.

But Dr. Makgoba, of the Medical Research Council, says black officials are also to blame for poorly carrying out AIDS policies since 1996, and for dabbling in discredited theories.

In 1994, when Nelson Mandela became South Africa's first black president, about 8 percent of adults in South Africa were infected with H.I.V. Today, the figure stands at 25 percent. More than half of this country's 15-year-olds will die of AIDS-related diseases, government officials say.

The Origins of the Epidemic

Hlabisa is one of the many impoverished villages of the Zulu people, the warrior nation that routed British troops in 1879 before finally being conquered. Today, villagers keep their traditions even though most are jobless and more than 60 percent rely on rivers and rain for drinking water.

The tiny professional class is made up of teachers, nurses, clerics and shopkeepers. Others work in faraway mines and factories, while farmers graze cattle and grow corn. They revere their king and respect the mayor and four local chiefs, who govern the community's day-to-day affairs.

South Africa's first AIDS cases emerged in the early 1980's, chiefly among gay white men who presumably contracted the virus through homosexual contacts in the United States and Europe. The black population's exposure was limited then by segregation and tight border controls with some neighboring countries where H.I.V. was spreading faster. But in the early 1990's, the white government eased border restrictions. In a few years, the epidemic exploded among blacks, who make up about 78 percent of the population.

The virus found fertile ground in communities like Hlabisa, whose ragged road carries workers through the district and through a game reserve where elephants, zebras and giraffes still graze, to the town of Mtubatuba and onward to the coastal cities of Richards Bay, Durban and beyond.

Today, researchers estimate that 60 percent of Hlabisa's men are migrant workers who often spend weeks or months away from home and often have multiple partners: wives in the village and girlfriends or another wife in the cities.

The subservient position of women, who have little power to negotiate in their sexual relationships, and a tradition of polygamy and multiple partners, particularly in rural South Africa, have also fueled the disease.

The apartheid government, which knew an epidemic was brewing, took no systematic action to stop it. After Mr. Mandela took power, the warnings were met with shock, denial and disbelief.

Doctors at Hlabisa Hospital were among the first to ring alarm bells here, producing annual statistics on H.I.V. infection rates starting in 1992. But many traditional leaders and politicians continue to assume that the disease primarily afflicts whites and foreigners.

Even today, professional men in Hlabisa boast over beers about extramarital affairs and the pleasures of unprotected sex. Some church leaders burn condoms and assail people with the virus as sinners. Prominent community members wither and die in silence because the disease is considered so shameful.

Hospital counselors and nonprofit groups regularly distribute condoms and offer awareness programs, but there is little evidence that their safe-sex messages are taking hold.

One recent morning, eight young women, all volunteer AIDS educators for Vusimpilo, a local nonprofit agency, gathered to practice the speeches they planned to present at community festivals and local schools. Use condoms, they said. Abstain from sex. Keep to one sexual partner.

But when asked whether they used those strategies themselves, not a single educator raised her hand. The women, in their 20's and early 30's, confessed that they felt educated, aware -- and powerless.

"For us Zulus, it has been a tradition for men to have extra women," Gugu Chakwe said helplessly. "We do ask them to stop, but it's up to them to change. If he doesn't want to use condoms, I can't do anything. If I say no, he might go and take another lady."

Nomusa Manqele, who trains the young women, admitted that she, too, felt powerless. "A lady asked me, 'What can I do if the boyfriend doesn't want to use condoms?' " she said. "I told her, 'You can leave him.'

"She said, 'I can't leave. I need money from this boyfriend to support my children.' "

"I felt ashamed." Ms. Manqele said. "I am an AIDS educator, but there was no hope I could offer her."

There is some hope. Hlabisa Hospital and local clinics have begun to offer an antibiotic to prevent opportunistic infections in people infected with H.I.V. The drug is best known as Bactrim, a trademark of Roche Pharmaceuticals.

By the end of the year, the Africa Center, a nonprofit medical research group based in nearby Mtubatuba, will distribute the nevirapine to pregnant mothers who test positive. One tablet taken during labor -- along with a single dose for the newborn -- can reduce the risk of mother-child transmission by as much as half.

Of the 50,000 people in Hlabisa believed to be infected with H.I.V., fewer than two dozen have access to life-saving drugs that have made the disease manageable in the West, doctors say. In the mud huts here, they are dying one by one.

Optimism Can Break the Heart

In one hut, hidden deep in the swaying grass, Nokulunga Ntshangase, 23, a lovely girl with a withered body, insists that she will survive H.I.V.

"I am getting married," she says.

But Ms. Ntshangase's father hangs his head when he looks at his daughter, whose enormous brown eyes float in her wasted face. He knows there will be no wedding.

"If she's better," he says sadly, "if she's able to wash, clean and cook, then she will get married."

The Rev. Zebulon Mthethwa, a retired Anglican priest, knows all about such stories. He dedicated his life to this community and to fighting apartheid. When democracy came, he thought he would retire and watch Hlabisa prosper.

But Holy Name Church has called him back from retirement. With so many people dying, they need extra priests to sing all the souls to the other side.

"One of my nephews, I closed his eyes," Father Mthethwa said. "I closed his mouth. I knew it was the same thing.

"People are afraid of talking about it," Father Mthethwa said. "They are afraid to say, 'Here is the danger that is coming.' But we must now become bold. We cannot just keep quiet. Because the truth is, we are simply vanishing."

Death and Denial

This article about the H.I.V. epidemic in South Africa begins a series that describes life in one ravaged community, Hlabisa. While the outlines of the crisis affecting Africa have been widely reported, these articles offer a rare, intimate portrait of the everyday struggles that burden one place.

Hlabisa is a poor Zulu area in the hills of KwaZulu Natal Province. A third of its adults are infected, a figure greater than in any other province of the country, which has the highest infection rate in the world.