Newsday, July 11, 2000
Laurie Garrett, Staff Correspondent

Matouvu is a major maker and supplier of coffins for the region of Uganda hardest-hit by AIDS. His workshop on the TransAfrica Highway sold 10 coffins a day in 1994, four child-sized.

"That was the peak," Matouvu said. "Now we are selling only one per day. I have decreased my number of employees...from 20 in 1994 to nine today. People are not dying at the rate they used to, so there's no business."

Layoffs in the casket business could be considered great news, especially given the possibility that AIDS, known locally as kativa- killer-might be in retreat. Though it is too soon to know, Matouvu's misfortune may be due to what experts believe is Uganda's successes in fighting AIDS.

"In 1982 the prevalence of HIV was 2 percent [of the population] in Uganda. In 1992 it was 30 percent. But by 1998 it was down to 10 percent," said Vice President Speciosa Wandira Kazibwe, who is also a doctor. Only two nations, Uganda and Thailand, have so radically reduced their HIV rates. When United Nations officials, policy analysts at the White House, World Bank leaders or Africa's own health leaders are asked what can be done to slow the relentless spread of HIV, they all point to Uganda. The country may not have achieved all that it claims, such officials say, but clearly Uganda is doing something right.

Uganda is the only country in the world that has mapped out a national strategy for attacking HIV, extending out to 2006. It has set a goal of reducing HIV prevalence to less than 5 percent. Crucial to the Ugandan strategy is recognition that HIV presents a challenge not just to traditional health sectors, but to every single facet of society.

"I think when we look at this globally that has to be the key," said Kathleen Kay of the University of Sydney in Australia. "In every possible way we have got to link HIV/AIDS prevention to development programs. Because AIDS is a development issue. It's as much an issue for the educational system as it is for health."

Kay, who helped map out the first AIDS global strategy in 1986 when she was part of the World Health Organization's original AIDS program, argues that every United Nations agency must have a viable HIV strategic plan. She is working on such a plan for the United Nations Development Program, and consults to UN AIDS.

"The problem is that we've taken this piecemeal approach to HIV/ AIDS for almost 20 years now. First we said it was just a problem for ministries of health, and then as we started seeing the devastation of the social sector and economies, we broadened things out a bit," Kay explained. "But it's really been in a chaotic fashion at best."

In the absence of any promising vaccines or cures, Uganda is a beacon as HIV rages in Africa. On New Year's Day there were 1 million sub-Saharan African children and 30 million adults living with HIV, according to the United Nations AIDS Programme. That's 5 percent of the region's total population. Another half percent of the population has perished from AIDS.

So any hope, no matter how slim, is desperately needed in this continent's epidemic.

Yet some dispute the encouraging figures from Uganda. The Rakai Project AIDS research center in Kalisizo has conducted surveys of southwestern Uganda that show only modest declines in HIV prevalence in urban areas and actual increases in rural communities.

Even in the urban studies, researchers warn, infection rates may not be as low as official Ugandan numbers indicate. Uganda, like most poor countries, bases its data on blood tests performed on women in pregnancy clinics, which may offer an artificially low view of prevalence. That's because women who have AIDS, or whose mates are ill or have died of the disease, are less likely to be pregnant, compared to uninfected women.

"Certainly when delegations come to the country they talk about success. But I think we need first to define the standards of success," argued Dr. Mohammed Kiddugavu of the Rakai Project.

"I think your standards depend on whether you are a politician or a scientist," chuckled colleague Dr. Nour Kiwanuka. "I remember when the president used that figure of 10 percent last year on World AIDS Day. And we were wondering, where was that figure derived?"

Masaka's coffin business could be down because the local death rate may merely be in a lull-a sort of generational cycle. In that scenario, Kiwanuka explained, HIV already saturated and killed off the vulnerable members of the generation that was between 25 and 45 in 1994. And adults who were then younger than 25 may now be infected, but the slow disease process has not yet pushed them into AIDS and death. So, another large cycle of death may yet come.

"It is now felt that we may not have a handle on the true situation in Uganda," Dr. John Rwomushana of the Uganda AIDS Commission said. The last time Uganda conducted a legitimate national HIV prevalence survey was 1988, he acknowledged, and most data since then have come from urban centers, such as Entebbe and Kampala. But rather than conduct another expensive national survey, the AIDS Commission has opted for bolstering the country's public health infrastructure, hoping in coming years to create good HIV surveillance centers all over the nation that can feed reliable data to the capital on an ongoing basis.

Nevertheless, the signs of behavioral change in Kampala and nearby Entebbe are unmistakable. The average age of first sexual intercourse among girls has risen from 12 years in 1990 to 16 years today, according to UN AIDS. That radically reduces the risk of spreading HIV among teenagers. In 1980 virtually no condoms were sold in Uganda. Last year 60 million condoms were purchased in the country, according to the Ministry of Health.

"And the knowledge of the people-95 percent of the people know what is HIV and how to protect themselves," Dr. Luc Barriere- Constantin of the UN AIDS office in Kampala said. "This is incredible!"

A major reason is President Yoweri Museveni, who has since 1986 made a practice of speaking of AIDS whenever he is in public. In May, parliament passed a law mandating that all senior government officials must also address some aspect of the epidemic each time they speak publicly.

"You don't have to look much further than Museveni for inspiration," insisted U.S. Ambassador to the UN Richard Holbrooke. "You can't get around the fact that if the guy on top is keeping his mouth shut, is in denial about the epidemic or just doesn't care, you're not going to get anywhere."

In contrast to Museveni, South Africa's Thabo Mbeki is questioning whether HIV even causes AIDS-indeed, whether a new epidemic exists at all. Zimbabwe's Robert Mugabe has in 20 years barely uttered a word about AIDS. And most other African leaders have demonstrated little concrete interest in their epidemics. Nigerian President Olusegun Obasanjo is trying to follow Museveni's example, calling for Uganda- style reforms in social behavior and HIV/AIDS programs. But his populace is slow to catch up with Obasanjo, illustrating that a bold leader, alone, cannot fight HIV.

In part, Nigeria is waiting for its own Noerine Kaleeba to emerge.

A robust woman who speaks impeccable Queen's English as a result of university studies in England, Kaleeba is a force to be reckoned with. In 1983 Kaleeba was a married mother of four working in Kampala as a physiotherapist at Mulago Hospital. She had heard rumors of a new sexual disease that was killing people in the distant Ugandan fishing village of Kansensero, but she paid such tales little heed until 1986 when her husband, Chris, fell ill in England. He had been working on his PhD thesis at Hull University when he collapsed, his body devastated by cryptococcal meningitis. British doctors diagnosed AIDS.

Kaleeba made her way to the UK, and watched her husband's struggle, as well as the kindness with which he was treated by Hull University medical staff.

After Chris died and Kaleeba returned to Uganda, she was shunned, and friends stopped inviting her to their houses. Kaleeba saw AIDS sufferers refused care by her colleagues and evicted from their homes by their own families.

"When I saw the attitudes of my fellow health care workers I said, 'This cannot be my profession.' I was driven by anger...I saw so many people abandoned by their families. In our history that had never happened before. I felt frightened. I said, 'My goodness, this epidemic is really striking at the core of our culture.'"

Though a British HIV test found her uninfected, Kaleeba didn't believe it. She assumed she was going to die of AIDS, so she gathered 15 friends and started a group in 1986 called The AIDS Support Organization, known by its acronym, TASO. Within a year, 14 of those TASO founders had died of AIDS, which, Kaleeba said, only strengthened her resolve.

In 1987 she was introduced to Museveni, and "I said, 'Your Excellency, I am Noerine Kaleeba. My husband has just died of AIDS and I would like to do something about AIDS.' He looked at me and said, 'Oh, my God, I'm sorry about your husband. But how are you?' I said, 'I'm OK.' So he said, 'Everyone! Help her!' And I left feeling like a hero."

Today TASO is the largest and most successful nongovernmental AIDS organization in Africa, boasting 40,000 staff and volunteers and clinics all across Uganda. Funded entirely through charitable donations both from Ugandans and foreign organizations, TASO influences every aspect of the country's AIDS effort: treatment, prevention, stigma, politics and education. Kaleeba now works at UN AIDS in Geneva, encouraging development of similar groups in other African nations.

Dozens of other locally generated organizations that have thrived over the years and strongly influenced public perceptions of the epidemic.

"We are reaching 2.5 million young people in Uganda, aged 15 to 24," boasts Jerolam Omach, 30, of Straight Talk, which saturates the schools with information about the epidemic, hoping to inform youngsters while they are still virgins. And they have their work cut out for them, Omach said, because, "in Africa we believe if you don't play sex your vagina will harden. And young boys believe if they don't play sex their penis will not grow. So we must break myths."

Once young people do become sexually active, another nongovernmental organization, the Commercial Markets Strategies Project, funded largely by the U.S. Agency for International Development, tries to sell them condoms. The group's Basil Tushabe said, "Our strategy is that within five minutes a person should be able to access a condom at any time."

Since 1991, Tushabe's group has sold 30 million Protector condoms. The condoms are sold to bars, markets and pharmacies for 50 Ugandan shillings per three-pack, which they aggressively push because the retailers are allowed to double the price to a hundred shillings, or about seven U.S. cents.

An adult who fears he or she may have become infected with HIV can see another charitable group, the AIDS Information Centre, which has conducted 465,000 tests since 1990, director Jane Namwebya said. Last year, she noted, "22 percent tested positive for HIV."

The AIDS Information Centre's slogan is "Ffuga obulamu bwo," or "Take control of your life." When clients arrive they pay the equivalent of $3 and are given ID numbers; their names are never recorded on any paperwork, guaranteeing confidentiality. Within two hours the individual is counseled and has test results.

When clients turn up positive for HIV, the Centre refers them to TASO, where the theme is "living positively with AIDS" and the goal is provision of humane, dignified care. At the TASO clinic in Mulago, counselors help patients find psychological and financial coping strategies. The harder job is that of the physicians who have little to offer their patients save basic antibiotics, malaria treatments and dysentery medicines.

Margaret Konsanze is so ill she must be carried into the cramped examination room by a TASO volunteer. Though only 29, Konsanze's rail- thin body and gaunt face give her a far older appearance. She coughs up blood and groans with pain. Dr. Isaac Lwanga, carefully scrubbing his hands before and after gently examining Konsanze, concludes she has tuberculosis that is particularly aggressive because AIDS has weakened her immune system.

Thanks to TASO's efforts, Konsanze will probably receive decent treatment. She will not be stigmatized here because of her HIV. She may even get over the TB, gain weight and be able to return home for a few more months of life.

Few of these services are available outside Uganda's larger cities. But the fact they exist at all in this African nation is something of a miracle. No other country on this continent can boast such a range of efforts and services and such little stigmatization of people with HIV. Nor can any other nation boast such open cooperation between government and nongovernmental services, charitable foundations, and foreign-funded organizations.

"I believe with effort a similar strategy can be adopted in different countries," the AIDS Commission's Rwomushana says. "But no country will have our historical conditions."

History has dealt Uganda a rather challenging deck of cards-one that many sources interviewed all over Africa insist will make this country's experience hard to replicate. From 1962 until 1986 Uganda was ruled by a series of exceptionally brutal dictators, the key one being Idi Amin. It is estimated Amin killed 500,000 of his countrymen. And for three decades most Ugandans lived daily under conditions of extreme terror and near, or absolute, starvation.

When Museveni seized power in 1986, he established the first semblance of civil society most Ugandans had ever experienced. Everybody in Uganda felt the change, as soldiers ceased to be forces of oppression and life suddenly was predictable, and safe.

"At that time there was so much euphoria! We have life again. Freedom again," Kaleeba recalled. "That same year my husband was dead from AIDS in June. So people had just started feeling good again and then AIDS comes."

One Ugandan after another said the same thing: Once they had tasted freedom and civility, there would be no turning back to the days of brutality, suspicion and hatred. Not for a dictator, and not for a virus.

"Because we had returned to sanity," Kaleeba insisted.

Museveni's early policies also indirectly enhanced the atmosphere for AIDS efforts, as he created a very decentralized government and discouraged reliance on foreign aid and international charities, preferring promotion of self-reliance. As a result, Uganda today has powerful local governments with which TASO and other charitable groups can work directly. The country is imbued with a strong entrepreneurial spirit and an economy that, despite the epidemic and Uganda's involvement in Congo's two-year war, is growing. Such a spirit of self-reliance has led to heightened ingenuity and determination in planning and sustaining their AIDS efforts.

"If you look at African countries, hardly any have done that," said Dr. George Tembo, a UN AIDS officer in Zimbabwe. "Everybody in the middle and lower levels can't stand there and wait for the top. It must be the initiative of the middle and lower levels to take the ball and run. If the political environment doesn't hinder you, if the leadership doesn't oppose condoms or claim HIV doesn't exist, then you have room to move."

On an international level, then, the situation is fairly complicated, as only a few nations have coherent strategies for tackling AIDS -programs that outside funders and political leaders can plug into. For most of the region there is no strategy, either at the local, national or international level.

The White House has resisted creation of an overall strategic framework for international HIV/AIDS efforts. As one top official put it, "we know how to do it, we know what works. Condoms, education, those sorts of things. Now just do it!"

Dr. Peter Piot, executive director of UN AIDS, insists that the only thing that can possibly motivate action from the top of most nations is recognition of the bottom line: HIV is bad economics. And bad politics.

"It is interesting to me that [President Paul] Kagame in Rwanda now wants to create a nationwide movement to defeat AIDS," Piot said in an interview recently. "And Rwanda is the one African society that has the traumatic history analogous to Uganda's.

"The key is to get some kind of movement in each country. TASO was such a movement," Piot continued. "But a strategy must be created within a society-we cannot do it. We can only supply support from outside."

Most African societies have, however, been dependent for decades upon outsiders: missionaries, former colonial governments, UN agencies, the World Bank, charitable groups. Further, autocratic leaders all over Africa actively discourage the sorts of self- initiative seen in Uganda, viewing it as a threat to their power. Most African governments are highly centralized bureaucracies that hamper, rather than help, private and public enterprise.

"I just don't see how the Uganda experience could ever help us here," Marvelous Mhloyi, dean of the School of Population Studies at the University of Zimbabwe in Harare, said with a sigh. "If AIDS is not a grassroots issue here now, it never will be an issue. Look, something like 2,000 people die here of AIDS every week! Yet nobody here dies of AIDS-have you noticed? They die of 'short illness' or 'tuberculosis' or 'a fever.' There is such persistent denial."

One out of every four adults in Zimbabwe is already infected, destined to die of AIDS. UN AIDS predicted last month that half of Zimbabwe's boys now aged 15 will one day die of AIDS. As foreboding as all of that seems, Mhloyi said, it is not enough to motivate grassroots action in Zimbabwe, a nation of severe political instability and collapsing economics.

"You can't 'live positively,' as they say at TASO, if you don't have basic food, basic medicine," Mhloyi insisted. "Life is not in our hands. Poverty itself stares at us on a daily basis. And when you see it looking at you, you can't think of HIV that might kill you in 10 years."

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