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Prosperity's Fatal Side Effect: New urban lifestyle spurs virus


DRESSED IN their finest, members of Zambia's young elite strolled into the elegant Maykusu Nightclub for a Saturday evening of dining and dancing to the hot rhumba rhythms of Zaire's Lumbumbashi Stars. Mosi beer flowed liberally and the dancers reveled into the morning hours.

But the joy peaked as musicians shimmied their shoulders to the repeated chorus of Le Sida, French for AIDS.

It may seem strange to find joy and dancing in a song that simply repeats over and over again the name of the deadly epidemic that has gripped much of Africa, but that is but one of the contradictions here.

Unlike the epidemic 1,000 miles away around Lake Victoria, Zambia's AIDS problem is relatively new, though growing. AIDS here is found in the two largest cities, Ndola and Lusaka, and is spread among young urban adults by the new sexual freedom that is also found in the other major centers of the continent's epidemic: Kigali, Dar Es Salaam, Kinshasa, Kampala and Nairobi.

DESPITE the best of intentions and an aggressive educational campaign, the fight against AIDS is being fought here by an overburdened health-care system that has difficulty coping with more immediate medical problems, such as a new, extremely deadly form of cerebral malaria, rampant malnutrition and a variety of tropical diseases that demand the bulk of the nation's health budget and attention. It also conflicts with some long-standing cultural traditions.

Zambia's battle with its AIDS epidemic is, like most things in the region, being waged against a background of continuing tensions with the West and with the apartheid regime of South Africa. Secrecy in the name of national security has shrouded much of the information about AIDS infection rates.

In times of relative prosperity, Zambia, a leading copper producer, has always concentrated its wealth in Lusaka, where construction, from high-rise office buildings to sprawling suburban housing, is once again booming. According to the UN's Food and Agriculture Organization in Rome, Zambia's agricultural problems have decreased markedly, and this year it will harvest a record 1.6 million tons of maize. That, too, fattens the coffers of urban banks and industries as increasing agricultural profits are invested.

Prosperity has ushered in an urban lifestyle conducive to the growth of AIDS. The nation's urban young adults find themselves the first generation with a significant disposable income, and are eager to enjoy the fruits of their nation's relative success.

Zambia has managed to educate an entire generation of young male and female civil servants, professionals and business executives. A handful have become wealthy; most are simply far more prosperous than their parents. The baby-boomers, those now in their late 20s and early 30s, strive to dress in hip western fashions, and most speak excellent English in addition to their tribal languages.

According to Zambia's most recent surveys, these young adults are the key target group for the AIDS virus: more than 10 percent, men and women equally, are infected with HIV-1. Men aged 30 to 35 in Lusaka have an even higher rate of infection: more than a third test positive for HIV. And the epidemic, among all groups, is doubling in size every eight months, nearly twice the rate of the United States.

"That's a key risk population, absolutely," said Dr. Subhash Hira of University Teaching Hospital in Lusaka. "They are people who have a lot of disposable income, they have moved away from traditional homes and are single people looking for employment or having easy money." Hira said Lusaka has very little prostitution, particularly compared to other major African cities. "What we really have here," said Hira, "is a free sexual atmosphere."

ACCORDING to Dr. Sam Nyawa, chairman of the government's Zambian National AIDS Surveillance Committee, 1,056 AIDS cases had been reported to the government as of last June. Nyawa said the figure is accurate because doctors are required by a 1986 law to report all cases.

"If you compare AIDS to other health problems we have here in Zambia," Nyawa said of the reported cases, "AIDS won't even appear on a scale. But we can't say, 'Let's wait until it does appear, until villagers are wiped out.' It is an epidemic, and we must fight it." That fight, said Nyawa, should focus on Zambia's AIDS hotspots - the cities of Ndola and Lusaka.

Dr. Eric Von Praag is the official World Health Organization AIDS representative in Lusaka, working closely with Nyawa. Von Praag said he is less confident of the figures.

The World Health Organization, which does not comment on specific countries, says in general that only 10 percent of all AIDS cases are actually reported in a typical African country. Von Praag said he believes the same ratio applies to Zambia, meaning that the nation of 7.1 million people could have a total of 10,000 AIDS cases. Nyawa said such an estimate for Zambia was absurd, adding that it is very unlikely the nation has experienced far more than about 1,000 cases of AIDS.

Von Praag said that part of the reason for what he believes is under-reporting are telecommunications and transport problems. In addition, there is a growing awareness in government circles that AIDS in children is usually misdiagnosed as marasmus or acute malnutrition. A recently completed study at University Teaching Hospital found that 20 percent of the children admitted to the malnutrition ward tested positive for HIV infection.

In addition, recent government studies show there has been a 60 percent increase in tuberculosis cases in Zambia. TB is a common opportunistic infection among people infected with the AIDS virus, and the government suspects this may indicate a higher incidence of the disease than statistics now show.

Nevertheless, said Nyawa, "Our situation is still quite containable. Serosurveys - blood screening - show that 98.7 percent of primary school children are uninfected. That means if we target young people we may be able to prevent the spread of AIDS in this generation. AIDS is still very much in the early stages in this country, but we aren't taking any chances. We are taking it as a priority."

As part of that effort, Zambia is waging one of the world's most aggressive educational campaigns against AIDS, surpassing anything being done in the United States. Throughout the country, posters exhort the nation's young adults to "Stick to One Partner" to avoid the scourge of AIDS.

The government's AIDS education campaign starts in grammar school, where children are given a brightly colored pamphlet depicting Kalulu the Rabbit saying, "Learn about AIDS and keep yourself safe! You cannot tell by looking at someone if they are infected, so for safety stick to one rule: No sex before marriage."

Secondary school students receive a more detailed pamphlet that describes the biology of AIDS and quizzes readers about their knowledge and prejudices related to the disease. One page depicts a prostitute who says, "Sex for sale? AIDS is the price! I think I'll take up farming - it's safer!" The pamphlet goes on to urge young people to have absolutely no sex before marriage, and remain faithful to their marriage partners. "Boys, have the strength not to ask!" it advises, and, "Girls have the right to say no!"

A similar theme forms the basis of the government's adult AIDS education campaign. Posters all over the country urge Zambians to stick to one partner, and depict marriage as the umbrella that fends off showering AIDS viruses. One prominent poster states simply, "Sex thrills, but AIDS kills."

ZAMBIAN President Kenneth D. Kaunda, who acknowledged that his 30-year-old son, Maguzyo, died last year of AIDS, has been more outspoken about AIDS than any other head of state. In an August statement before the ruling party congress, Kaunda, a devout Christian, said, "It is not enough for believers just to kneel down and pray because there is no secret in this except to face the situation as it is. Doctors are telling us to stick to one sexual partner, male or female. If we cannot do that out of strong, moral principle or religious beliefs, we will have to do so as a matter of self-preservation because if we do not behave well in this respect, AIDS will catch up with us - and sooner rather than later."

In Zambia, where 70 percent of the people are Christian and missions run by the Jehovah's Witnesses and Jimmy Swaggart are prominent, all condom campaigns have generated strong opposition. The groups oppose the use of condoms and argue that such birth control also promotes promiscuity and adultery. According to Von Praag, there are plenty of condoms in family planning offices, but their use is not promoted because of protests from the Christian community, and young adults are generally unaware that condoms can help protect them from AIDS infection. No condoms are distributed in the schools.

To date, no studies have determined what effect Zambia's educational campaign is having. Young Zambians call AIDS "slow puncture": like a slowly deflating tire because people with AIDS waste away. The use of the "slow puncture" phrase lends a certain comic element to discussion of the disease, apparently making it easier to shrug off.

Health workers say that halting the epidemic requires a sharp change in cultural patterns, some of which are deep-seated.

Last year University Teaching Hospital focused on the spouses and sexual partners of people infected with the AIDS virus. Couples were informed that condoms provided the only barrier to the otherwise inevitable transmission of the virus between them. Despite such aggressive counseling, less than 10 percent of the couples opted to use condoms.

At Chinkankata Hospital some 60 miles to the south of Lusaka, social worker Thebisa Hamukoma regularly confronts AIDS patients, their lovers and relatives about their attitudes toward AIDS. Last year, 183 out of 680 admissions to her hospital were diagnosed as having AIDS, and it became obvious drastic steps had to be taken to slow the spread. Most of the people in the rural area are members of the Tanga tribe, which, Hamukoma said, carried out an unusual practice that promoted the spread of AIDS - "ritual cleansing."

"It is traditional among the Tanga people," said Hamukoma, "that the bereaved spouse is supposed to be cleansed following a death. If the cleansing does not take place, the surviving spouse will be haunted by the dead one for life." Cleansing is accomplished when the family selects a partner for the bereaved spouse, and the pair must engage in a night of intercourse.

If the bereaved spouse is infected with the AIDS virus, which is usually the case, it could be passed on during the ritual.

Hamukoma said she and her colleagues have devoted a lot of effort to persuading families and spouses to forego the ritual, or replace it with some other rite that might safely serve the same purpose. "Half the spouses counseled had a negative reponse to the idea," she said. "But in ninety percent of the cases the families pushed the spouses and an alternative to ritual cleansing was found."

HIRA said the practice is limited to two Zambian tribes, and careful counseling seems to have dramatically reduced the rite. Despite this success, the epidemic continues to expand in the area through nonritual heterosexual intercourse.

"AIDS is not a problem in the villages, the way, for example, syphilis is," Hira said. "HIV is a disease of the better-educated, well-to-do, those who are single, the young population, mostly in the cities. There is no doubt it is heterosexually transmitted, and the entire risk is based on sexual behavior."

Because the disease is transmitted heterosexually in Zambia, foreign scientists have eagerly moved in for short-term research projects. In general, the tremendous costs of AIDS treatment and research have made Zambia's health officials agreeable to such collaboration, though it has also brought problems.

Early in the Zambian epidemic a group of American scientists tested hospital patients for AIDS infection and then released the information to western reporters before discussing it with their Zambian collaborators. When the number of those infected was reported to be large, several Zambian scientists temporarily lost their jobs, and political tensions with the West grew.

"In the past people have exploited our situation," said Hira, "blown it up, and in the process there was a political backlash. And what happened was that the entire medical research effort suffered, not just in Zambia, but everywhere. Because it is the exchange of knowledge between researchers on various continents that is so important. No medical problem has ever been properly addressed by 'safari research.' We have people come in for two weeks and they go back and tell you, 'Look, you have a problem in this area.' That is wrong. The research should be done by local people, or people committed to the region on a long-term basis."

All collaborative research projects on AIDS are now cleared through the Ministry of Health's Ameristo Njelesani, who said the real task for his office is to protect AIDS patients from overzealous drug companies and foreign scientists.

OVERALL, there is concern in Africa that the continent's people will be asked to serve as guinea pigs in the war on AIDS. At a news conference two months ago, leading U.S. AIDS researcher Robert Gallo, of the National Cancer Institute, suggested AIDS vaccine trials might best be conducted in Tanzania and Uganda, rather than the United States. Tanzanian officials bristled, saying no drug or vaccine should be tried on Africans before it has been tested on volunteers in the country in which it was developed.

President Kaunda said in an interview that this represents an alarming event. "I wish that some international regulations could be formulated," he said, "which would place controls on these matters. How could anybody think we should be guinea pigs here? Human beings! I can't understand that. We are all one human race, and for any part of it to be treated as guinea pigs, because of their race or I don't know what, is wrong."

AIDS also has increased Zambian antipathy toward the western press, which has charged that the government is covering up the true extent of its epidemic, an accusation Njelesani vehemently denies.

There is, however, no doubt that a certain amount of secrecy shrouds Zambia's AIDS situation. A technician at University Teaching Hospital said, "It is absolutely forbidden to give out information about the prevalence of HIV infection. We cannot tell you anything. It's because of them." The technician pointed to two young soldiers sitting nearby. "The South Africans ran news stories saying all our boys in the army were infected, every single one of them. And people started saying nasty things, like the Zambian army would be the first one in history wiped out without firing a shot. And these chaps - the soldiers - got quite upset."

Last year, the government conducted a survey of infection rates among its soldiers, and officially denied the South African reports. But the survey findings have never been made public, and sources at WHO in Geneva say even the agency has not been able to obtain the data.

ZAMBIAN reticence to release further information about AIDS also comes at a time when the nation is locked in a battle with the world's largest lending institution, the International Monetary Fund. Since AIDS is hitting the educated elite of the nation, Zambian officials are concerned about the long-term economic impacts of the epidemic. The World Bank has made financial forecasts of the AIDS epidemic, predicting dire circumstances for many African nations. Zambia is struggling hard to cut its losses, control the epidemic and limit its effect on the economy. Zambian leaders fear that exaggerated accounts of the impact of AIDS could cut off vital international loans.

Throughout the world, governments are having a difficult time balancing present health priorities against the danger that is acquired immune deficiency syndrome.

But for nations such as Zambia, whose economies are in constant need of external support, any additional health spending is made at some pain. This is particularly true when the nation is in the grips of other epidemics. Young Zambian adults are falling to a new, drug-resistant form of cerebral malaria. Between January and August of this year, University Teaching Hospital saw 26,524 cases of the new type of malaria, more than 9,000 of which required hospitalization.

Four months ago, a team of West German and Zambian researchers released results of a nationwide survey on malnutrition, finding that 55 percent of Zambia's children under 4 were dangerously underweight, and malnutrition accounted for 48 percent of all child mortality.

In the face of such enormous usual medical problems, AIDS becomes just another threat to an already tenuous existence. The question facing Zambia, and other stricken African nations, is whether the disease will prove to be one threat too many.

NEXT: The Monetary Cost


Dancing to the Beat of a Musical Battle Cry

The No. 1 song heard on radios and in record stores from Lusaka to Kinshasa is "Attention Na SIDA," or "Beware of AIDS." It was recorded more than a year ago by Zaire's most popular muscian, Franco Luambo Makiadi, who bills himself as "The Grand Master Franco," and his T.P.O.K. Jazz Band, and has remained on the pop charts of Central Africa ever since. It is common to see crowds roaring "SI-DA! SI-DA!" to the beat.

"Oh! Le SIDA! Une terrible maladies!" shouts Franco. Going back and forth between French and Kilunda, Franco issues a veritable battle cry against AIDS:

Oh! AIDS! What a terrible disease!

AIDS! A Disease that pardons no one.

AIDS! A disease that attacks all persons.

Oh, it's something to fear, this AIDS.

All medicines are impotent before it.

Keep your body, I keep mine.

Protect yours, I protect mine.

AIDS! It ravages all societies.

There is fear.

Europe and America accuse Africa of being the origin of AIDS.

All sections of society are victimized by AIDS.

Babies, children, youth, workers, bureaucrts, politicians, women, men - it is the same for all.


Copyright © 1988 -Newsday, Publisher. All rights reserved to Newsday. Reproduction of this article (other than one copy for personal reference) must be cleared through the Newsday.

Information in this article was accurate in December 27, 1988. The state of the art may have changed since the publication date. This material is designed to support, not replace, the relationship that exists between you and your doctor. Always discuss treatment options with a doctor who specializes in treating HIV.