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New York Times
Food Scarcity and H.I.V. Interwoven in Uganda
David Tuller
December 25, 2007
MBARARA, Uganda - At the AIDS clinic here, the stories are brutal. A young cattle herder, infected with H.I.V. along with his wife, tells me that all four of their children died before turning 3.

H.I.V. and AIDS patients awaiting help at a center in Gulu, Uganda. Many families are on the edge of starvation.

A mother of five, also infected, reports that after her marriage she was forced to have sex with her husband's three brothers, in accordance with tribal tradition.

And most patients I meet say they and their families scramble to survive from meal to meal, never far from the edge of starvation. Many say their H.I.V. drugs have drastically increased their appetites and made them crave food even more.

"Sometimes I am so hungry," a 44-year-old widow says. "It's intense. My whole body is shivering from hunger. Even when I have just finished eating, I am hungry again minutes later. It's such a problem, because I don't always have food."

As a journalist turned graduate student in public health, I am in Uganda for five weeks as part of a research team investigating whether "food insecurity" - a persistent difficulty in finding enough to eat - undermines the effectiveness of H.I.V. treatment.

I am interviewing dozens of patients - anonymously, as is standard in such qualitative research - about what they eat, how much food they have, whether they grow it or buy it and whether the side effects from the medications are worse if they take the pills on an empty stomach. Our team also wants to know whether costs related to treatment limit their ability to cover basic foods and whether hunger forces women to offer men "live sex," or intercourse without condoms, in exchange for food or money.

The study is part of a collaboration between the University of California, San Francisco, and the Mbarara University of Science and Technology, a prestigious institution in this small, bustling city southwest of Kampala, the Ugandan capital. Other patients will be followed for two years to monitor how food insecurity affects their drug regimens, and illness and death rates.

Western donors have increased the distribution of antiretroviral drugs in sub-Saharan Africa. But they have done little to make sure that the recipients do not starve to death or have to choose between paying for transportation to the clinic and feeding their children. Studies like this one seek to demonstrate that packaging food aid with H.I.V. drugs or reimbursing patients for travel can actually improve health and save lives.

Uganda has been hailed for its success in reducing H.I.V. infection, with adult prevalence falling to just below 7 percent in 2005, from 15 percent in 1991. That success is not apparent from my observation post, a small corner office at the ramshackle clinic here.

Every weekday morning, more than 100 people pack the clinic. About two-thirds are women, many swathed in brilliant colors. Men often refuse to be tested or seek treatment. The patients cluster on benches in the hallways, jostling infants on their knees and waiting to see clinicians or counselors and pick up their monthly supplies of medication.

Women, in particular, confront what medical anthropologists call "structural violence," the social, cultural and legal constraints that often rob them of control over their own and their children's destinies.

Their accounts of beatings, neglect and rape, of unfaithful and absent husbands and boyfriends, do not exactly showcase the human male's most appealing qualities. More than one woman tells me she became infected because her H.I.V.-positive partner had threatened her with abuse or abandonment if she refused his demands for "live sex."

"I used to tell my husband that we should use condoms, and he outright refused," a mother of four says in a tone more resigned than bitter. "If I wouldn't have live sex with him, he would refuse to bring home food and take care of the children."

Most of the respondents grow some or all of their own food or they cultivate other people's gardens in exchange for basics. The staples are matoke, a carbohydrate-heavy mush made from green plantains, and posho, a carbohydrate-heavy mush made from maize flour. They are served with "sauce," if available - beans, a paste made from groundnuts, or another protein source. Meat, chicken and fish are luxuries. Many families can afford them just once a year, if that.

To make ends meet, parents have to engage in a desperate triage, navigating between bad choices and worse ones.

If they let their hungry children eat everything that the family grows, they will have nothing to sell at the market. If they do not sell part of the harvest, they will not have cash for the monthly clinic trip for the medication that keeps them alive.

But every time they go to the clinic, they lose a whole day of gardening or other work and spend cash they could otherwise use for the children's diets.

"I feel bad that I have to spend that money for transport when I could have spent it on something else," one mother says. "And then the days I'm at the clinic, of course, I come knowing that I won't do anything that day."

Listening to the accounts of poverty and deprivation, I feel helpless and miserable. I promise myself I will never again take a decent meal for granted.

I want to empty out my pockets and shove dollars at every patient I interview. Instead, I buy them a cup of chai, a milky African tea, from the clinic canteen. The chai costs 300 Ugandan shillings, or 18 cents in dollars. For most, that is a luxury beyond their means.

I wonder sometimes what is the point of researching this? Why not just give food to people so obviously in need? But international donors demand data and documentation. They want proof that an intervention will reduce the total misery index before they will shell out millions of euros for new programs, even if the need appears self-evident.

I get to return home when my work here is done. I will analyze my data, write up my findings and hope that what I have done makes some small contribution to change.

The women and men I have met will trek to the clinic month after month, if they can scrape together $5 or $8 for the bus fare. They will consult with the doctor, grab their drugs from the pharmacy and wonder where they will find enough beans and matoke to feed the kids tomorrow.



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