Aids in South Africa

R.W. Johnson

An Aids epidemic is coming to South Africa. The countries with the highest Aids incidence in the world are grouped in East-Central Africa – Burundi, Tanzania, Uganda and Malawi are probably the greatest sufferers of all – and gradually the virus has been making its way southwards. It has indeed been possible to work out South Africa’s ‘HIV prevalence lag time’: nine years behind Burundi, eight behind Tanzania, Uganda and Malawi, seven behind Zaire, Zambia and Rawanda, five behind Kenya and Angola – and so on. South Africa has been protected not only by its position on the continent’s southern tip, but by its social and economic isolation: trade sanctions and the inhibitions on tourism have been an ill wind blowing some good. However, 60 per cent of the world’s Aids victims are to be found in Africa – and there is no prospect of South Africa avoiding the scourge.

What this means is that we shall soon see an epidemic of African proportions raging in a far more highly developed society than any of those so far affected. South Africa is a relatively sophisticated society with levels of medical care and expertise unparalleled elsewhere in Africa and, because the virus is coming to South Africa relatively late, far more is known about its nature, its treatment and its likely economic effects, than was the case when it hit the less developed societies to the north. It is a bit like sitting in an oceanographic laboratory, waiting for a tidal wave to hit – and the evidence suggests that we now have months, not years to wait.

The predominant incidence of the virus has already moved from a relatively restricted ‘ghetto’ of mainly white male gays into the far broader (and mainly black) heterosexual population. Everything we know about that population’s vulnerable health status, its powerful resistance to counsels of sexual abstinence and contraception, and its lack of access both to condoms and to Aids information – suggests that the epidemic cannot possibly be stopped.

How bad will it be? In a paper to a recent conference in Durban on the economic impact of Aids, Jonathan Broomberg, Malcolm Steinberg and Patrick Masobe constructed a complex actuarial model to take into account the fact that the epidemic’s doubling time is likely to slow down as it progresses. In the very early stages the number of adults aged 15-34 who are HIV+ doubles every six months – a rate seen in South Africa in 1986. But the doubling time should rise to 14 months in 1991, 16 months in 1992, and so on up to a plateau level of 34 months in 1995. By that point nearly 1.6 million people will have the virus, but the incubation period of up to ten years means that the cumulative total of Aids deaths will be only 47,000. Thereafter, say Broomberg et al, the snowball effect will really begin to tell. For 2000 they predict 5.2 million HIV+ cases and 666,000 cumulative Aids deaths; for 2005 7.4m HIV+ cases and 2.9m deaths, and for 2010 8.2m HIV+ cases and 6.6m cumulative deaths. It is worth noting how, in the mature period of the epidemic, the fatality rate catches and even passes the infection rate. That is, between 2005 and 2010 the number of HIV+ cases increases by less than 1.2m, but more than 3.6m extra Aids deaths occur in the same five-year period because by then a really large ‘backlog’ of HIV+ cases has been built up.

All such projections are, of course, extremely responsive to the assumptions made – and all data on the incidence of the disease have to cope with more or less large-scale under-reporting. For purely technical reasons some under-reporting is inevitable under African conditions, but it also occurs because Aids is such a sensitive subject, particularly given the assumption – widespread on all sides – that it is, or will be, a predominantly black disease. Blacks are bitterly aware that many whites greet as almost heaven-sent any force likely to curb the explosive growth of the black population, which in any case they see as disease-ridden, sexually hyper-active and promiscuous. There is, accordingly, a pronounced – one could say fatal – tendency for discussions of Aids to get side-tracked into furious attempts to deny that stereotype.

Sensitivities of this kind, together with a fear of scaring off tourists and investors, have led some African governments into deliberate cover-ups – most grievously in the case of South Africa’s neighbour, Zimbabwe. In 1987 the number of reported Aids cases in Zimbabwe was reduced on the orders of the Ministry of Health. Both hospitals and the blood transfusion service were told that only doctors could be told of a donor’s HIV status: the donor himself was not to be told, while doctors were informed that they could report Aids cases only to the Aids Control Programme. Aids sufferers were officially discouraged from telling anyone of their illness and doctors were accused of misdiagnosis and hence over-reporting of the disease. This disgraceful policy ended only with the appointment of a new Minister of Health in 1990. Its effect was to delay energetic action against the spread of the virus in its most critical phase.

While South Africa shows no sign of replicating this disastrous example, public propaganda is extraordinarily muted when one considers the fact that the country is now only months away from the critical point when the proportion of the adult population who are HIV+ reaches 2 per cent. From what is known from studies elsewhere in Africa, it is as the epidemic reaches the 2 per cent line that its growth rate becomes exponential: the curve of the graph then becomes almost vertical and only begins to level out when around a third of the population is HIV+.

The Durban conference, a landmark in the wide participation it attracted from the academic, government and business worlds, produced both hard data and some tough-minded thinking about the unthinkable. The conference’s key data came from a study of 14,376 women of all racial groups attending antenatal clinics in October-November 1990. This reliably large sample showed a HIV+ rate of 0.76 per cent. Assuming a doubling time of 12-14 months, this means that an overall HIV+ rate of about 1.5 per cent will be reached by the end of 1991, with the 2 per cent line being reached in May-June 1992. The implication is that in the months remaining before that date South Africa really ought to be the subject of a saturation TV, radio, poster and leaflet campaign: of this there is no sign. The Government has allotted the princely sum of £300,000 for Aids education and neither the ANC nor Inkatha gives the subject much time. There is no active conspiracy of silence: merely embarrassment and complacency on a huge scale.

What can be done? The answer is threefold: an education campaign aimed at increasing condom-use and generally encouraging safer sexual practices; the careful (and non-oppressive) monitoring of prostitutes; and a major drive against other sexually-transmitted diseases, for everything suggests that the prevalence of such diseases elsewhere in Africa has been a major factor in accelerating the spread of Aids. These measures would do nothing to prevent a major epidemic, but they could slow its progress and perhaps cause the HIV+ graph to level off at a lower point than that seen in countries to the north.

Some would favour a far tougher line. The Cubans are the chief exemplar here, insisting on compulsory blood sampling and enforced quarantine for all those who emerge as HIV+. Many Cuban troops repatriated from Angola have in effect returned home into permanent quarantine, the unfortunate sufferers only being allowed out into society on a strictly chaperoned basis. It would appear that this regime has been highly successful in preventing the spread of the virus, but even the South African Communist Party, which has strong ties with Cuba, does not advocate similar measures here. Indeed, both the SACP and ANC are vociferous in resisting the notion of Aids-testing their Umkhonto guerrillas on their return home, although these guerrillas include many men who were stationed in Angola and fought alongside the same Cubans now subjected to compulsory testing.

A great deal of heat has been generated by discussions of the HIV status of Umkhonto returnees, but in the end the issue may almost be a red herring, for the progress of the epidemic hardly depends upon them. A regional breakdown of the 1990 ante-natal sample shows that the overall 0.76 per cent rate was actually constituted by a rate of only 0.16 per cent in the Cape (logically enough: the virus is advancing from the north and the Cape lies furthest to the south); 0.53 per cent in the Transvaal, 0.58 per cent in the Orange Free State and 1.61 per cent in Natal and Chief Buthelezi’s domain of Kwazulu. It is tempting to think that the reason for Natal/Kwazulu’s unhappy prominence is that Durban, the region’s centre, is Africa’s largest port – but impressionistic evidence suggests that the HIV+ rate is highest in small-town and rural areas, pointing to land-borne infection from neighbouring Mozambique as the more likely source.

Of all South Africa’s blacks, it is the Zulu people who have known the greatest trials and tribulations in recent years: drought, poverty, overcrowding and unemployment all reach record levels in Kwazulu, and the area is marked by exceptional rates of civil, political and criminal violence. To all that one must now add the unhappy certainty that within South Africa the Zulus will be the first and perhaps the greatest victims of the Aids scourge. One cannot but note how often in Africa Aids appears to feed on war and civil strife – in Uganda, Ethiopia, the Sudan, Mozambique and Angola the coincidence is plain enough. It is not merely that all diseases spread faster among a war-weakened populace: war in Africa means famine, accelerated population movement, widespread rape and the dislocation of settled familial units. Natal/Kwazulu has seen over six thousand die since 1985 in what has, effectively, been a Zulu civil war between Inkatha and the ANC; perhaps one should have realised that where war comes, Aids follows not far behind.

What will the effects of the epidemic be? Researchers from East Africa speak of an hour-glass shaped population pyramid, with the very old looking after the very young and much of the intervening age groups cut down. In South Africa, which displays an exaggerated form of rural dependence on remittances from urban wage-earners, the deaths of a significant number of remitters could lead to a widespread collapse of the rural economy, with much of the country transformed into a vast refugee camp.

Alan Whiteside, the conference organiser, pointed out that three out of four available projections for Zimbabwe were for an actual population decline over the next decade, but he didn’t himself believe that such a götterdämmerung was likely. Although South Africa’s total fertility rate has been slowing down – the average black woman has 5.1 births now, compared to 6.8 in the Fifties – Broomberg and his colleagues thought it most improbable that Aids could do more than cut population growth to a minimum of 1 per cent per annum by 2005. South Africa’s problem is still going to be having too many people, not too few.

The economic cost of Aids will be high. As Whiteside puts it, ‘South Africa is in the unenviable position of facing a Third World epidemic with a population that may expect First World resources to be devoted to the care of the sick.’ The area of uncertainty is inevitably large here: people don’t die from Aids directly, after all, but from their loss of immunity to other diseases. In South Africa most deaths will probably result from run-of-the-mill diseases like TB and dysentery. Broomberg, Steinberg and Masobe estimated that by 2000 treating the epidemic would consume between 19 and 49 per cent of total health expenditure, and 34 to 75 per cent by 2005. Even if one takes median figures of 34 per cent and 54 per cent, a great deal of ‘crowding out’ of other forms of health care seems inevitable.

The indirect costs of the epidemic – the loss of valuable man-years – clearly depend in some measure on how the educated élites behave. On the one hand, they have the resources and opportunities to lead lives of considerable promiscuity; on the other hand, they ought to be among the most responsive to anti-Aids information and propaganda. All one can say so far is that the auguries from the rest of Africa are not good. Rolling direct and indirect costs together, Broomberg and his colleagues from the Wits Medical School suggest that Aids could cost South Africa up to 4 per cent of its current GNP by 2000 and up to 9 per cent by 2005: heavy costs indeed, but sustainable nonetheless, provided – and it’s a big if – that GNP growth picks up in the post-apartheid era. Meanwhile, corporate South Africa has begun to react: scholarships endowed by large companies like the Anglo-American Corporation now routinely require applicants to undergo HIV tests.

It is widely assumed that the coming of majority rule will result in a major setback for women’s rights, as the central norms of society cease to be set by the traditional chauvinism of the white male and are dictated instead by the far greater chauvinism of the black male. But Aids could well strengthen – and will certainly complicate – the challenge to those norms now mounted by a younger generation of African women. At present all serious feminine assertion is undermined by alarming rates of sexual harassment and rape, a major threat for black girls from the moment they achieve puberty – not a few black teachers have been necklaced for raping their charges. ‘Jack-rolling’ (random rape-and-robbery) by teenage gangs is a common feature of township life: in Aids-prone societies such crimes can easily amount to murder.

Epidemics are highly divisive social events, frequently leading both to the blaming of the ill and to the ill seeking to revenge themselves on the healthy – dangers which seem particularly likely in South Africa where the different racial groups are for ever trying to blame others, while seeking the moral high ground for themselves. In the past many blacks have tended to accept almost as a law of nature the fact that whites typically enjoy safer, healthier lives than they do, but this isn’t something that the new black élites are likely to put up with. The inevitable conflicts over the direction of health spending – how far it is to be targeted at the hapless masses, how far at the élites – could, of course, be fought along class and not racial lines. It is even possible that Aids will be seen as a national crisis, necessitating a united response from all social and racial groups, but, sadly, it is more likely that it will feed on, perpetuate, and even inflame traditional grievances.

As yet these are but dark imaginings: the media and the élites of all races are far too taken up with the lobster quadrille of negotiation politics to give much attention to anything as embarrassing as Aids. South Africa awaits the deluge with only half an ear cocked for the sound of the great wave to come.