Manzini, Swaziland—Mrs. Precious Dube, a 50-year-old, no-nonsense nurse matron, is exactly the sort of person you want in charge of your local health clinic if a deadly epidemic hits. Her mountainous Southern African nation has the highest prevalence of AIDS in the entire world—nearly one in every three people between the ages of 18 and 49 is HIV positive.
Ten years ago, Precious Dube feared that the killer virus would cause her country to disintegrate. Today, she is hopeful. Swaziland is part of the unprecedented multi-billion-dollar, continent-wide campaign to provide Africans with antiretroviral drugs (ARVs). This huge effort, two-thirds of it funded by the United States, has already prevented the death of millions of people.
“People in America have saved the Swazi Nation,” she says with feeling. “If you had not helped us, our people would be sleeping in the streets and dying of disease and hunger. Instead, now, we are about to contain AIDS.”
“Please give us another five years of help,” she asked. “We are winning. We have made it up to a middle level. Help take us up a little bit higher. Our people are taking the ARVs and becoming productive again. As our healthier population goes back to work, we will be able to fund health programs ourselves.”
Precious Dube’s growing optimism is echoed across the wide swaths of Eastern and Southern Africa that the AIDS epidemic hit hardest. The latest statistics are astonishing. In 2003, only 50,000 people in Africa were taking the anti-AIDS drugs. Today, that figure is 7 million. In Africa, the majority of people living with AIDS are women—59 percent, by one calculation. In 2003, hardly any HIV-positive pregnant African mothers had access to the medications that could have reduced the risk of transmission to their children. Today, nearly 1 million kids are alive because America and the other donors got the drugs to their mothers.
Public health experts have learned that “treatment is prevention.” The millions of people taking the ARV medications are much less likely to spread the disease further. New infections worldwide are down one-third from the peak year of 1998, with Africa accounting for most of the decline.
The campaign against AIDS in Africa has already set two world records. It is the most effective foreign aid program since the Marshall Plan helped rebuild Europe after World War II. It is also the largest single medical intervention ever. The successful effort is also an extraordinary tribute to international solidarity, as gay American activists joined courageous Africans to force governments to pay attention and big pharmaceutical companies to back down. The containment of AIDS also refutes the cynical assertion that trying to help the Global South always ends up as pouring money down a rathole.
Yet this victorious program, which spans an entire continent, is hardly getting any publicity at all.
What’s worse, instead of building on this success, the Obama administration is flat-lining its budget request for next year, at $5.7 billion, although even more Africans will need the life-saving drugs. (The largest American program, the President’s Emergency Fund for AIDS Relief, or Pepfar, is budgeted at $4.35 billion, and the United States will contribute another $1.35 billion to the Global Fund to Fight AIDS, Tuberculosis and Malaria.) The administration’s timidity is particularly hard to understand, given that prominent Republican legislators are already on record supporting more money. After all, it was George W. Bush who unexpectedly tripled funding for AIDS in Africa back in 2003, and who deserves tremendous credit for the much brighter picture today.
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My own concern about AIDS in Africa is personal. Starting in 1978, I spent four years based here in Swaziland, reporting on war and apartheid across the region (see James North, “Black Power on the Move in South Africa,” The Nation, August 30, 1980). During my last visit, in 2008, the atmosphere was pessimistic. Death notices filled the newspapers every day. There were 80,000 orphans, in a nation that has just 1.1 million people; everyone explained that the gogos, or grandmothers, were struggling to look after them. I had already lost some friends: a quiet, friendly store clerk; a corpulent, smart but bombastic high school teacher. Another friend, a professor at the University of Swaziland, told me back then: “Sometimes I look at the students in my biggest lecture course, who are 19, 20, 21 years old. There they are—talking, flirting, giggling, full of life just as students always have been. And then I think that if nothing changes, ten years from now one out of three of them will be dead.”
Six years later, the fear and despair are lifting. The number of Swazis on ARVs has risen to 79,000—which is 7 percent of the entire population. My friends tell me that everyone who wants the drugs can now get them, free of charge. Perhaps most encouraging, the prevalence of HIV/AIDS has sharply declined among people under age 25.
Stigma and shame are now the biggest obstacle. A Swazi activist organization carried out a survey in 2012 revealing that 45 percent—nearly half—of the people who are HIV-positive still refuse to go to clinics for medication because they are ashamed that their neighbors will learn they contracted the virus. This result, similar in other African countries, shows that stigma is still causing people to die in agony.
My friend Sanele Mdluli is one of Swaziland’s leading activists, who courageously wrote a national newspaper column called “My Life with AIDS” back in his early 20s. He is now 30, with a cheerful new girlfriend. He has always been a curious young man, and he has now somehow developed a love of opera; his mobile phone ringtone is a Verdi aria. He started taking ARVs last year, and he is healthy and energetic. He spends his time conducting workshops all over Swaziland, appearing on radio call-in programs and talking to youth groups.
He told me a story to show the power of stigma: “A old man in a rural area out on the Lebombo Plateau approached me. He was taking the ARV tablets, but he kept them hidden away from his homestead, out under a tree, so his family would not know. He wanted me to tell his wife for him. It took time, but I encouraged him to tell her himself. He came back to me, laughing. It turned out his wife had been hiding her tablets in the washing basket.”
Nurse Matron Precious Dube’s office in a Manzini clinic is cramped, busy but spick-and-span. She has to put four patients in rooms intended for two, and line up more beds in the hallway. She had just lost another of her nurses to AIDS the previous weekend. “She had been coping, still working,” Dube said. “Then she took sick leave for two weeks—and died.” Dube has lost count of how many funerals she has attended. “Now I only have time for relatives,” she said.
Dube said the worst years were 2003 and 2004, before the help started to arrive. In the pre-AIDS era, the local hospital saw 300 patients a month; the average last year had risen to 9,000. She explained that ARV drugs alone are only a part of what is saving Swaziland. “It’s the whole health package,” she said. She ticked it off on her fingers. “America provided HIV testing. Expertise. Technical assistance. You gave us those mobile classrooms you see outside, to train more of our nurses. Your help for HIV/AIDS has raised our standards, and improved the quality of all our healthcare.”
At first, there were understandable fears that such an immense, continent-wide program could be weakened by corruption, but there have been no major scandals. Most African nations now have independent newspapers and radio stations, and one of the first things the journalists would have noticed is any large-scale pilferage or profiteering connected with the life-saving medications.
The campaign to contain AIDS is also challenging because most Africans are so poor. The Swazi bus companies just announced a 50 percent fare hike; the amount, still trivial by rich-world standards, is a significant burden for people who travel to clinics every month for their medications. Nurse Matron Dube has responded with characteristic vigor. “We send people out on motorbikes into the rural areas to make sure patients are complying with their drug regimens,” she said.
Back in 2000, the consensus in the global public health establishment was that the new ARVs, which had started saving lives in the rich countries as early as 1996, were far too expensive for Africa and would never work there anyway. The big pharmaceutical companies that had patented the drugs charged $10,000 per person a year, which was out of reach for nearly all Africans. And one US official said that Africans would not be able to take the medications on time because many of them “do not know what watches or clocks are.” People ridiculed his clumsy statement, but he did reflect the conventional wisdom.
So as people with HIV/AIDS in the rich countries who had started on the ARVs were rising from their sickbeds and going back to work, people in Africa continued to die in the millions. But then an inspiring international solidarity network changed history. Eric Sawyer, an American gay man now in his 60s, is as responsible as any other single person on earth for the millions of lives saved in Africa. Sawyer, who was one of the co-founders of the militant organization ACT UP, helped organize the first protest that demanded justice for people with AIDS all over the globe, outside United Nations headquarters in 1990. Sawyer, a tall, lean man who is modest about his historic role, was arrested more than thirty times as he and his fellow activists picketed Big Pharma headquarters buildings and disrupted Al Gore’s 2000 presidential campaign, demanding that the outrageous drug prices be lowered and help offered to everyone, no matter where they lived.
Sawyer and his American friends found allies overseas. A barrel-chested Ugandan army major named Rubiramira Ruranga met Sawyer and other members of ACT UP at the 1992 AIDS conference in Amsterdam. Major Ruranga had been HIV-positive himself since 1989, but he kept his status to himself. Some years later, I met him in Kampala, and he told me, “At that stage, I was sitting around waiting for my death. Then I saw these young guys, dancing, moving, singing, carrying around banners that said, ‘We have AIDS.’ I could not believe it.” He beamed at the memory. “My heart changed. If people talk of being born again, then I was born again. I said, ‘Ah, I am not going to die. Period. I am not going to die.’ ”
The major was so inspired that he went home, publicly announced his HIV-positive status, and became known across Africa as he demanded treatment for all. In South Africa, the brave former anti-apartheid activist Zackie Achmat and an outspoken judge named Edwin Cameron criticized their own government’s criminal denial that HIV caused AIDS. In 2001–04, Médecins Sans Frontières conducted a pivotal study in South Africa that proved drug compliance rates among Africans were just as high as, if not higher than, those in the rich world.
By 2003, the international campaign was making an impact. Sawyer and his allies called on the United States to increase its budget for AIDS in Africa to $3 billion a year, a figure they felt privately was impossibly high. But then George W. Bush stunned them. In Bush’s January State of the Union address, he launched Pepfar by asking Congress for $15 billion over five years, which tripled the existing funding. In 2008 Congress renewed Pepfar for another five years, this time raising the allocation to $48 billion.
Sawyer, who works today for UN AIDS (a branch of the world organization) in New York City, is still “dumbfounded” by Bush’s act. “I was shocked and really, really grateful,” he remembered. (Bush, in his memoir, Decision Points, dismisses the theory that he proposed Pepfar to compensate for the violent invasion he was about to launch against Iraq. Whatever his motivation, his decisive act may just be another proof of Dr. Martin Luther King Jr.’s conviction that even people who have certain views we abhor are capable of great humanity.)
The good news today about the AIDS epidemic should not let us forget that an awful—and preventable— tragedy did happen. Dr. Peter Mugyenyi is a legendary Ugandan physician who has been fighting the illness since the 1980s; he was seated as the guest of honor in the Capitol visitors’ gallery when George W. Bush announced the birth of Pepfar. Mugyenyi’s memoir, Genocide by Denial: How Profiteering from HIV/AIDS Killed Millions, is an excruciating account of how he attended international conferences at which the new medications were lauded, and then flew back to his clinic in Kampala where he had nothing to offer his patients, year after year after year. His book is dedicated to “the millions of men, women and children who would have lived, but died simply because they were too poor to pay the price of the life-saving drugs.”
What’s more, the successful campaign against AIDS depended on two major strokes of luck. What if HIV/AIDS had not also struck a proud, articulate gay community in the heart of the rich world, people who were eager to fight back, on their own behalf and for others? What if George W. Bush had continued the do-almost-nothing policy of the Clinton administration, instead of boldly surprising everyone?
There are still serious dangers ahead. South Africa has been experiencing “stock-outs”—spot shortages of ARVs, which has caused de facto rationing; people line up outside clinics before dawn to make sure they get their tablets. In Swaziland, a supply bottleneck for a chemical reagent meant that Sanele Mdluli could not have prompt follow-up testing to see how well his drug regimen was working, and sometimes he waits for seven hours in the Mbabane government hospital for the medications themselves.
More money will be needed, even if these particular problems may not have been directly caused by the stagnant level of overall funding. Approximately 16 million Africans are HIV-positive and still not receiving medications, and as stigma continues to drop, they will start coming in to be tested. Anti-AIDS fighters now believe that you should start hitting the virus as soon as someone tests positive, instead of waiting for CD4 cell counts to drop before putting people on medication. So far, first-line medications are still working well in Africa, but they may wear off, and more people will need the more expensive (and still patented) second- and third-line drugs that many of my friends in New York City are already taking.
The Obama administration’s hesitance to ask for more money is a moral failure. It is also politically inexplicable. AIDS funding is one of the few issues in Washington with bipartisan support. In December, fourteen Republicans, including some from party’s conservative wing, were among the forty signatories of a letter requesting more funding to help 12 million people by 2016. Advocacy groups in Washington, such as amfAR (the Foundation for AIDS Research) and Health GAP (which Eric Sawyer helped start), are lobbying vigorously to expand the anti-AIDS campaign.
In a more just world, people like Nurse Matron Precious Dube, Sanele Mdluli and millions of other hard-working Africans would be able to pay for their healthcare themselves. Many of the people I know here in Swaziland are quietly embarrassed that their nation needs outside help. But there is no alternative. Let us give former president George W. Bush the last word. When he tripled AIDS funding back in 2003, he told Americans: “A doctor in rural South Africa describes his frustrations. He says, ‘We have no medicines. Many hospitals tell people, you’ve got AIDS, we can’t help you. Go home and die.’ In an age of miraculous medicines, no person should hear those words.”