The Coming Plague (59 page)

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Authors: Laurie Garrett

BOOK: The Coming Plague
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Her illness began a few months ago, Noticia explained, when she noted an abscess on her neck. Later similar purplish things appeared all over her body. She poked a bony leg out from under the sheets and barely nodded in its direction, guiding the visitor's eyes to what seemed to be a Kaposi's sarcoma tumor on her calf.
Noticia gulped for air, and continued.
“I became very weak. I developed fevers and chest tightness and coughing.” As if to accent that point, Noticia cleared her throat and a fit of coughing ensued.
“Initially she thought she had TB,” Kidenya explained while Noticia rested. “We started to treat her for TB, and at first she responded. But then after a month the coughing returned and she had large swellings on her cervix.”
Noticia whispered something in Swahili, and Kidenya told the visitor, “She is saying that she knew it wasn't TB. Now, she says, she is twenty-three years old but she feels as if she is a hundred. She is feeling weak, her limbs cannot carry her body. She feels like sleeping all the time.”
With obvious reluctance, Noticia related the story of her travels to Kenya, her work in Sofia Town, and the typist job she had recently been forced to quit because she was too weak to push the keys.
As Noticia finished, Tkimalenka spoke softly to the inert form lying on the ground, then replaced her sheet. Noticia watched anxiously, and seemed
relieved when Tkimalenka assured her the other patient was still alive.
Outside the cell Kidenya and Tkimalenka agreed that both women would be dead before the end of the week.
The grim picture repeated itself in one chamber after another, and a social pattern emerged from those willing to discuss their lives before AIDS struck: most of the men were former combatants in the Uganda-Tanzania war and/or traveling salesmen and smugglers who regularly crossed the region's borders to trade with counterparts in neighboring countries; most of the women had worked at some recent time as “disco girls,” barmaids, or prostitutes, and several, like Noticia, had traveled outside the Kagera District to ply their trades.
Mythologies were instantaneous companions of history in the communities surrounding Lakes Victoria, Albert, Edward, and Kivu. Whether people were by nationality Ugandan, Kenyan, Tanzanian, Burundian, Rwandan, or Zairian, they all told tales in early 1985 of bewitched fabric, Juliana's disease or “slim disease,” and the witches, “whores,” or visitors who brought it to their people. The Mhaya women, considered particularly beautiful by the men of the region, were also commonly referred to as prostitutes, and in local Swahili dialect the word
Mhaya
was used interchangeably with the word
kahaba
, prostitute.
“One aspect of that notion is quite true,” Tkimalenka, a Mhayan, said. “You get prostitutes in Dar from all regions. It is fair to say that the majority of prostitutes are coming from this region. But the people who are dying are not all Mhaya. So we can't accept the notion that AIDS is a disease of the Mhaya.”
Still, Bukoba's young men claimed that AIDS was spread by women.
“People are aware of the girls. Afraid of them,” twenty-eight-year-old Henry shouted over music in the Bukoba disco. A bachelor, Henry declared that he had “no intention of getting married. I am looking for a girl, but I can't choose which girl has AIDS or doesn't. I am very afraid, because it is death, you know. No medicine. Perhaps I will wait to marry, wait until there is a cure.”
And the women, most of whom now boycotted the disco, said with equal certitude that the Juliana disease carriers were all men.
“I know my boyfriend is seeing other women when he travels to this place or that place,” a young hotel clerk explained. “But what can I do? When he comes home he is so handsome and I reach out and say, ‘Oh, darling, darling,' and all is forgiven.”
The Tanzanians of Kagera were adamant that the disease came from Uganda, and with equal certainty the Rakai residents across the border pointed their fingers at the Tanzanians. Most people didn't know what a virus was—there was no word for it in Swahili, the closest approximation being
vinidogodogo
, or very little thing. But they did know that evil existed and could be manipulated by witches and sorcerers to inflict harm on their enemies.
It made sense, then, to assume that the new disease came from old enemies.
Kidenya, Nyamuryekunge, and Tkimalenka rejected such superstition and searched for hard facts. They counted the sick and the dead, knowing their total represented a mere fraction of the true AIDS tally. Villagers knew the disease was incurable and therefore wouldn't make arduous journeys on foot to district hospitals. Nevertheless, by the end of 1985 the Kagera District's hospitals had seen 206 AIDS cases, 35 of whom had died in the facilities. Kidenya guessed that they were seeing 5 to 10 percent of the cases.
Blood samples collected by Forthal from local residents were analyzed at the CDC, revealing that antibodies to HTLV-III/LAV were present in 41 percent of the first hundred patients diagnosed symptomatically by the doctors.
Of particular concern to Kidenya and Nyamuryekunge was the discovery that people with AIDS were about five times more likely to have had a series of injections for some reason during the previous two years than were other patients in their hospital.
It worried Kidenya that in America AIDS was spreading via the dirty needles used by people addicted to narcotics. The local practice, born of economic necessity, was to reuse syringes and needles so often that the tips had to be sharpened on whetstones so they could still puncture human skin. Such was the custom in his own hospital, Kidenya said. “But for the time being we believe the problem is not so bad in our clinics. Our people know they must at least try to be clean. But, you see, there is another type of drug supplier, an injectionist. For us, these people are very hard to find. They hide in the fields or whatnot. But they may happen to get hold of a syringe and perhaps some antibiotics. And without any medical knowledge they sell injections. So, you see, the people may go to them. And surely these injectionists do not worry about sterile needles.”
The problem had only worsened since the villagers had heard of AIDS. Knowing that the licensed doctors had no cure for the disease, those who suspected they might have Juliana's disease turned to the injectionists, who, like the snake-oil salesmen of America's Wild West, claimed their potions could cure anything.
To show his visitor the true scope of the Kagera District's AIDS problem, Kidenya negotiated privately with the regional party leader for a petrol ration and organized a trip north toward the Ugandan border. The first stop on the tortuous, muddy drive was the Bunazi Rural Clinic, staffed only by medical assistants and midwives. The chief medical assistant gave a tour, anointing each concrete hole with an illustrious title, such as “pediatric ward” or “maternity ward.” But few rooms had beds, there was no surgical theater, and the pharmacy had little more than chloroquine and aspirin. In a small side room a woman held pieces of paper, each bearing information about patients. A man was bent over a microscope, studying samples of blood, urine, or stools. No other equipment graced the room.
“This is our pathology laboratory,” declared the medical assistant. As he said this, a gust of wind swept all the samples and papers onto the dirt floor. The medical assistant led his visitors on to a general men's ward. As was the case in Bukoba, the term AIDS was never used, but two men were pointed out as suspected HTLV cases. Both were war veterans, coughing from tuberculosis and obviously dying. The assistant explained that usually such cases would be transferred to Bukoba, but there was no petrol for the truck. Asked how many AIDS cases had been sent from Bunazi to Bukoba, the medical assistant said only six.
Asked about syringes, the medical assistant pointed to a small kerosene-fueled autoclave containing several steel syringes and other equipment awaiting sterilization.
An hour further along the muddy road a small village was perched on the Ugandan border. The area was occupied for nearly a year by invading Ugandan troops in 1978. Then Tanzanian soldiers had bivouacked there while battling the Idi Amin government. The village bore the scars of war: bullet holes along the walls, abandoned, rusted vehicles, the complete absence of any valuable supplies.
Tkimalenka parked in front of the only building in the tiny hamlet that didn't sport bullet holes. A bright-faced, energetic young woman stepped out of the modest tin-roofed structure and, recognizing Tkimalenka, grinned and shouted,
“Karibou, Bwana! Jambo!”
She urged the group inside, where, as eyes adjusted to the dark, three large, barren concrete rooms came into focus. In one there were three beds without mattresses. “They took the mattresses in the war,” the village paramedic explained. In another there was no furniture, but a strong cord hung from the ceiling. “This is where we used to weigh the babies to see if they were well. But that was before somebody stole the scale, which hung from the cord.” The third room was her office, containing a wooden chair, a small steel desk, and a bare wooden shelf.
“This is my office,” she said proudly. “Where I keep track of the health of everybody in the village.”
Atop her desk rested a foot-long shiny steel box. She opened the box to reveal two glass syringes, ten needles, and a dead fly resting in fetid water.
“Do you use these syringes?” the visitors asked.
“Yes, when we have something to give. Right now we have nothing. But sometimes we have vaccines for the children, or antibiotics. So then, yes, I use these,” the young woman answered.
She described how she sterilized the equipment. Without electricity or kerosene, she couldn't use an autoclave. She had no alcohol with which to swab the needles. Before any round of injections she would hang a steel pot full of water on a tripod over a wood fire outside, boil the equipment, let it cool, and inject whoever needed vaccines or medicines. In such a situation it wasn't usually possible to sterilize the needles between each patient, she explained, but she was able to make sure that the needles
were clean from one period of use to another. Proud of her work, and of the polite smile on Kidenya's face, the young woman graciously thanked the group for their visit. Later, when the young woman was out of earshot, Kidenya admitted that the sterilization procedure concerned him.
Back in Bukoba the group discussed the implications of such severe shortages of syringes. If one child in the village became infected with the AIDS virus, all the preschoolers might be infected in a single day's measles immunization campaign.
“Yes, yes, that is very bad. But what about the blood supply?”
Nyamuryekunge shifted his bulk in his chair and reminded the group that he was a surgeon. “It is most difficult for me because we do not have the AIDS blood test.” No one could find the prospect of transfusing contaminated blood more alarming than a surgeon, given that virtually all surgical procedures entailed loss of blood that must be replaced to ensure patient recovery. Yet a single blood test cost more than Tanzania's annual per capita medical spending of less than three dollars.
“You see, when I have an elective operation, not an emergency, but the operation itself requires a transfusion, then I'm not very keen to perform that operation,” Nyamuryekunge said. “But when the patient must have emergency surgery, then either the patient dies of AIDS in five years or he dies now. So in that case I give the blood now. Save the life now and let's pray the blood is not infected with the virus.”
Kidenya sighed and said he hoped that the steps they were taking to educate the people of Kagera about the disease would soon stop the epidemic. Or that the Americans would shortly find a cure.
“It pains me to care for an AIDS patient. It really pains me. Because whatever I give I know it is not helping the patient,” Kidenya said. “I don't fear contracting the disease, but it pains me to know that whatever I do, whatever book I turn to, it's useless. Your heart is not settled at all. At times I feel the disease is torturing our patients too much. I would like a disease which kills quicker. This one is too slow in killing. The patient wants to see you, demands your help. The help you cannot give.”
Mr. Rutayuge, the hospital's wiry, older administrator, listened. It was his task to order supplies from Dar es Salaam and then fight like hell to see that they reached Bukoba intact. Now the doctors couldn't tell him what to order. Nothing, they said, would help. And so many were dying in his district that Rutayuge began to enter their names in the ledgers where he once itemized supplies and revenues.
“For so long the young people have been running around, not listening to their elders. Even before the war with Uganda some of them were running around. Crazy. They don't listen to the old ways. After the war it was worse. Discos, prostitutes, babies, so many babies!” Rutayuge's frail body shuddered; he seemed to be fighting back tears. “Now some of the elders say to them, ‘Look here, we told you! Now you are sick. You are paying for all your running around.'”
Rutayuge appeared to be a practical man, not the sort who normally waxed philosophical or grim. He was a hospital administrator who, day to day, devised ways to replenish medical supplies for a rural clinic that hadn't “officially” received anything in weeks, perhaps months. With no budget, but plenty of ailing patients, Rutayuge negotiated deals with Ugandans, Rwandans, Burundians, even distant Kenyans, exchanging local goods for fuel, bandages, streptomycin, sheets, bedpans, painkillers for the dying, vaccines for the young, and aspirin for the rest.

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