The War against HIV

Ugandans are learning a new way to fight AIDS. Christians are showing them how.

John Nsamba waits outside his mud hut deep in the Ugandan hill country, knowing he soon will be among those buried in the banana groves that blanket the landscape with lush greenery.

“Slim,” the euphemistic term that Ugandans have given to the disease of AIDS, has aged him so significantly that Nsamba easily looks 20 years older than his 42-year-old body.

With their mother and eldest brother already dead, the three remaining Nsamba children will be without immediate family, land, or household, because their father has been a tenant farmer. Vincent, who at 18 is the eldest child in the household, covers his face and sobs into his red T-shirt at the prospect of assuming the role of head of household when his father dies. His sister, meanwhile, cares for their younger sibling and attends a nearby primary school.

In this equatorial African country of 18 million, nearly every Ugandan family, whether rural or urban, rich or poor, Christian or Muslim, has been visited by the aids epidemic. AIDS has been no respecter of persons, infecting the dirt-poor families in rural villages as well as those residing in the plush compounds on Kololo, one of the seven hills within Kampala, the capital city of 800,000.

One in six

In 1988, five years after HIV was discovered in Uganda, scientists sampled the blood of 11,000 people and found that 1 in 16 was HIV positive. Today, it is estimated that 1 in 6 is HIV positive. The worldwide rate is 1 in 250, with 90 percent of new infections coming via heterosexual transmission. In Rakai, a southwestern district of 350,000, seropositive rates of 50 percent can be found in village and trading areas.

The AIDS Weekly, published by the Centers for Disease Control in Atlanta, reports that nearly 2 million Ugandans carry HIV, and there are an estimated 300,000 with aids symptoms.

Speaking on state-run Ugandan radio, Elizabeth Madra, a physician active in the AIDS Control Program, warned last year, “The nation is in danger of losing most of its people.” Although Uganda has one of Africa’s highest birth rates (3.4 percent annually), researchers project that the country’s population-growth rate could reach zero by 2002 and decline thereafter, due primarily to aids. A 1993 study by the Uganda Virus Research Institute and the Medical Research Council found that half of all adult deaths in a region of 15 rural villages were in seropositive individuals.

Other studies show transmission is spreading widely among teenage girls. Of 2,000 Kampala teens hospitalized in 1992 for AIDS, 300 were male and 1,700 were female. Health officials are watching transmission rates in teens closely, because 57 percent of the population is under age 16. There are an estimated 1.5 million children who have lost at least one parent, putting extraordinary stress on the traditional extended family. The hardest-hit rural areas are populated mostly by the very young and very old. A generation of breadwinners has already succumbed to the epidemic.

Ugandans, unlike other African peoples, and in many ways like no other populace in the world, have engaged their common enemy and are responding to the HIV crisis with a warlike mobilization. The Uganda government, still laboring to overcome the 17 years of internal war that ended in 1986, has actively encouraged Christians and other religious leaders to be on the frontlines in the war against HIV.

The result has been an unprecedented level of cooperation among government bureaucrats, religious leaders, international relief agencies, and medical researchers. Although sharp, sometimes angry, debates occur with regularity over condom use, the role of traditional medicine, and other issues, many Ugandans realize they are waging a battle for their country’s viability. Even the army is involved and has issued T-shirts that say, “National Resistance Army. AIDS kills. Avoid casual sex.”

Whether working in orphan care, medical research, public-health education, or hospital treatment, Ugandans are using what they call a “multisectoral” approach against the virus. The two-year-old national AIDS Commission, composed of government, community, religious, and medical leaders, is being replicated in 39 districts around the country so that leadership from each distinctive sector of society is actively engaged in combating the spread of HIV.

On the edge

As the country’s survival instinct has kicked in, Uganda has unexpectedly found itself on the cutting edge in program development for changing the behavior of its people. HIV prevention is being incorporated into schools, churches and mosques, workplaces, and the news media as the number one policy objective. Because literacy levels are low in many areas, there has been a dramatic turn toward the arts—song, drama, poetry, storytelling, painting—as a means of coping with the emotional dynamic of death and dying, reinforcing behavior change, and in-patient care.

Recently Michael Cassidy, a leading evangelical from South Africa, noted why Africans are becoming more resourceful. “It is becoming evident that Africa is being marginalized in terms of aid and compassion priorities from the rest of the world,” he said. “Africans are seeing that we are basically on our own. This means a new sense of responsibility for our own destiny.”

At the surface level, Kampala appears to be a capital city quickly recovering from years of armed conflict that began in 1971 with Idi Amin’s reign of terror. In 1990, a new Sheraton hotel opened and already is swollen with Western tourists. Retail stores are filled with eager consumers. Among other factors, one of the country’s present economic worries is the falling value of the U.S. dollar, which has the unwelcome side effect of decreasing the value of foreign assistance.

Below the surface, however, Kampala’s private pain can be seen. Not far from the city center, Hussein Seemuyamba, 22, and his crew of five workers, ages 9 to 18, make wooden coffins seven days a week. Seemuyamba has made coffins since 1988 and became shop manager when the owner died in 1992. At one time, they would make only coffins to order. Today, they work continuously, and every coffin sells, costing between $30 and $150.

As in most other parts of the world, condom use had engendered the sharpest debate in Uganda. Hardly a day passes when the leading, state-run newspaper, New Vision, does not publish an article pitting condom-use advocates against the “anti-condomites,” as they are labeled here.

The debate over condom use and the place of sexual abstinence has created unexpected alliances within the Ugandan people. Born-again Christians find themselves in harmony with African traditionalists and Roman Catholics. Some Anglicans, academics, and medical professionals end up allied with business and government leaders and the press, favoring “quiet promotion” of condom use in addition to stressing sexual abstinence. “Human beings are human beings,” explains David Sentamu, Masaka district administrator, defending the government’s policy.

Patient care

Ugandan studies have shown that the greatest risk factor in HIV transmission is location. And in the war against HIV, there is no battle line more evident than in the Masaka and Rakai regions.

Kay Lawlor, an American doctor working at Kitovu mission hospital in Masaka, a city of 100,000, changed her whole approach to dealing with the epidemic one day when a mother burst into tears on hearing that she did not have HIV. “She said, ‘Now we will get no help,’ ” Lawlor recalls. “That went right through me. Help should not depend on the diagnosis. It should depend on the need of the person. It says something not so nice about society when it would be better to have AIDS so that you can get help.”

Many relief workers, in their intense focus on those suffering with AIDS, have unwittingly put AIDS into an exclusive category. Meanwhile, other individuals are just as sick from malaria, tuberculosis, and a rogue’s gallery of other communicable diseases.

To combat this, most hospitals do not segregate AIDS patients. They focus treatment on aggressively fighting the infections that come as HIV weakens a person’s immune system.

In Kampala, Miriam Duggan, the outgoing medical director at Nsambya Hospital, which, with 360 beds is the second-largest in the country, has put together a well-trained force of counselors who visit AIDS patients in their homes. One counselor, Christine Namuteei, says, “When we go with food and drugs, there is a great sigh of relief.” Most hospitals have taken the additional step of assisting AIDS patients in setting up “income-generating projects.” After receiving a small amount of capital, patients will buy and sell charcoal, chickens, or mats.

At Mengo Hospital, run by the Anglican church and the oldest hospital in East Africa, HIV-positive women gather for a weekly support group on “living positively with HIV.” Since the virus can remain dormant for many years, most people who are HIV positive do not realize it. When they eventually find they are, severe depression is common. Counselors are trained to help individuals cope emotionally and to teach them how HIV is transmitted.

In most cases, hospitals are not using AZT or other costly and experimental AIDS drugs. The money to pay for such drugs does not exist. Yet, Uganda is one of the few places in the world actively using traditional or herbal treatments against diseases brought on by the virus. Mengo Hospital, with government encouragement, recently opened a clinic for “traditional healers” to offer its services in a conventional setting.

“There are quacks among both traditional healers and medical doctors,” says John Rwomushana, who is special assistant to the National AIDS Commission. “But there is no cure for AIDS today. The majority of Ugandans know that there is no cure.”

In the upcountry of north Uganda, where rebels and refugees are still a major concern, Edith Wakumire and other Christian women formed Uganda Women Concerned Ministry, an interdenominational group, to educate people in rural villages and to care for orphans. A large grant from the AIDS Care Education and Training program, based in London, has helped set up the program. Wakumire says a family is thrown into turmoil when a husband dies of AIDS. In one case, she says, a man died leaving five wives, one of whom committed suicide. A total of 22 children had to be absorbed by the clan.

A generation of orphans

In unison, the cries of young black children fill the room: “Oh AIDS, why did you come? You destroyed the power of Africa. Where shall we go? You kill teachers. You kill doctors. You kill soldiers. You kill businessmen. Oh AIDS, where shall we go?”

So continues the litany that students, ages 7 to 16, at Masaka Baptist School have memorized. School officials keep a logbook showing that 50 percent of the 560 students have lost at least one parent, mostly due to the virus.

Masaka Baptist headmaster Vincent Lubega-Zaake says the rising number of orphans has overtaxed families and clans. “When the number keeps growing, we wonder what are we going to do. Very few families are able to accept unrelated orphans into their homes.”

With no free primary education in Uganda, education of orphans and other young children has proven to be a monumental task and been a major focus of international relief and child-development organizations.

In a region south of Masaka hit even harder by the AIDS epidemic, one school was closed because too many parents on committees had died. Jacques Masiko, Compassion International (CI) director for Uganda, says, “They were very desperate, and we had to help these people.” Working with local leaders, CI and the African Rural Outreach and Development organization helped to launch Mirembe Academy.

Living conditions for rural students can be very primitive. One household not far from Mirembe Academy is headed by Proscovia Naasiuun, her widowed aunt, and her widowed sister-in-law, whose husband is buried under banana trees next to their home. Proscovia has gained the admiration of Miremba headmaster Michael Katakbira. “I am very pleased that [she] encourages all orphans and widows who are in this clan to put some force behind going to school.”

Uganda’s cities are not friendly toward orphans and young children. At a church in the Nakulabye slum of Kampala, only four teachers in a child-development center care for 415 children. Administrator Carol Mastaba says 70 percent of the children live in one-room dwellings. She says the city hardens the personalities of orphans, causing them to have severe behavioral problems on top of frequent malnutrition and disease. The government has been overwhelmed by the magnitude of the problem and has yet to document the number and identity of orphans.

At the development center during a February Saturday morning, hundreds of young children were being prepared with Bic pens, notebook paper, and school uniforms for the next school term between sessions of singing American summer-camp songs: “Whose side are you dancing on? Dancing on the Lord’s side!” accompanied by the boys’ drum band.

Lessons for others?

Edward Delgado, CI’s Africa director, says other countries, especially the United States, have a lot to learn from the Ugandan war against HIV.

“I feel extremely encouraged by what Uganda has done. They are taking ownership of the problem. They have identified the problem and are working at all levels,” Delgado says. “Uganda, in fact, should be a model to the rest of the world. Even in surrounding countries, there is nothing that is as organized.”

The methods that are successful include establishing parish-level health committees. Namirembe Anglican diocese in Kampala set up grassroots committees to engage an entire community in HIV education and prevention. Agatha Seuyimba, diocesan health officer, says, “We may not all be infected, but we are all affected. We say, take care of your neighbor.”

John Ekudu, pastor of Kampala Baptist Church, says the church’s youth group has formed the Cross and the Virus, an interchurch teens group. They send out drama teams to local secondary schools to show how lifestyle choices have long-term consequences.

Another group of youths organized an HIV program fundraising event. One day 200 teens from different areas of Kampala took hospital beds through the city streets, going from business to business asking for donations. Enough money was raised to donate funds to a dozen programs. “It’s a case of trying to get them to do things and be creative as opposed to saying, ‘You’re bad. You can’t change,’ ” says Nsambya Hospital’s Duggan. “They have a national theme song of what they want to be. The words include the phrase, ‘Arise, Arise. Live a healthy life. We build a new nation.’ It’s youth ministering to youth. Young people want to change, but they don’t know how to start. We don’t just look at sexual behavior—we look at honesty, truthfulness, integrity.”

Richard Otto, a Conservative Baptist missionary for 14 years in Uganda, has watched the church grow dramatically in spite of HIV and the war years. “There is tremendous influx into the church. In 1983, we had 100 congregations. Now there are over 500 Baptist groups.”

He has been moved by the people’s ability to care for one another. “If you are going to be sick, Uganda is the place to be,” Otto says. “They know how to be with people. It’s called ‘the presence,’ and it’s very much a part of this culture. They know what to do.”

Way of the Cross

The words have ancient roots, but the context is 1994 Africa: “We adore you, O Christ, as you carry your cross along the dusty roads of Masaka, Uganda. We make the way of the cross in the homes and at the bedside of those with AIDS. We bless you because through this suffering you have redeemed the world.” Using a personalized wording of the Way of the Cross liturgy, each week AIDS counselors make their rounds in the villages of Masaka and Rakai.

A local batik artist has painted on large white cloth a person holding an AIDS patient dying in her lap, along with the words of the ancient Christian liturgy. Each station of the cross has a sufferer’s name at a different stage of disease. Station ten: “Jesus is stripped of all his garments—They put her out of the house; kept her clothes, saying they wouldn’t fit her wasted body. They told her to go to her grandmother’s to die. Once there she was again rejected—stripped of all, even her right to belong. Juliet was returned to the hospital, like an unwanted commodity.”

What the artist illustrated in rural Masaka is daily life in urban Kampala for Peruth Openu, who learned she had HIV after her husband “took another lady,” as she delicately describes it.

Today “the home is in chaos,” Openu says. Her teenage children, Andrew and Nathalie, face the prospect of losing both parents, and Peruth’s sick husband, Nathan, requires constant care.

“When I think I am suffering and I don’t deserve it, I think of the sufferings Jesus Christ underwent. He carried the cross. Each time I’m lifting my husband, it makes me love Jesus more than ever before,” Openu says. “Andrew does look to God. Nathalie, she’s angry. I tell her there is a greater Papa in heaven. The only hope I know is that God cares. He does when you cling to him. His promises are true.”

By Timothy C. Morgan in Kampala.

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