A Wave of Death, Surging Higher

By Richard Morin

GINGINDLOVU, South Africa -- Sister Priscilla Dlamini clutched a corner of her billowing black wimple as she pointed down the muddy dirt road that runs past the Holy Cross AIDS Hospice and disappears into a vast field of sugar cane swaying in the breeze.
"The first house, there, the white one, you see it on the right?" she said, her thick finger tracing the path of the road to a thatched roof barely visible above the cane. "The father and the mother died of AIDS; so did the boy and two girls. That pink house over there, seven died. And there. All eight dead."
Her hand swept back toward the horizon to cloud-shrouded mountains. "Everywhere between here and there are empty houses. In the mountains, it is even worse. And where there are people in the houses, there are graves beside them."
Death is never far away in the heart of what people here call the AIDS belt , a region in rural KwaZulu-Natal Province that stretches along the Indian Ocean from Richards Bay 80 miles southwest toward the port city of Durban.
This is where South Africa faces the full fury of the AIDS pandemic and its social, economic and political devastation. It is also here that the South African government confronts an awful truth: There is too much to do and too little to do it with. Deaths from AIDS complications will continue to rise for five years and perhaps for much longer.
"For a whole generation, it is too late," said Sister Priscilla, 55, a nurse. "The deaths are increasing every month. The dying is just beginning."
One out of nine South Africans -- about 5 million people -- are infected with HIV, the virus that causes AIDS. No country has more people who are HIV-positive. By 2010, AIDS is expected to cut life expectancy in South Africa almost in half, from 68 years to 36. The problem is particularly acute in KwaZulu-Natal. A recent government study found that 37 percent of all pregnant women in the province were HIV-positive, or about 10 percentage points higher than in all of South Africa.
A majority of South Africans fault the government for doing too little to stop the spread of HIV-AIDS, according to a national survey by The Washington Post, the Henry J. Kaiser Family Foundation and Harvard University. The proportion who say AIDS is the country's top problem has nearly doubled since 2000, from 13 percent to 24 percent.
The government has been slow to act in the face of the pandemic. President Thabo Mbeki startled the world health community in the late 1990s by publicly doubting that HIV caused AIDS, and then by championing the drug Virodene, a so-called AIDS cure that turned out to be little more than a toxic industrial solvent.
The government has announced that it will begin distributing anti-retroviral drugs free to those with HIV in a pilot test at five hospitals in Gauteng Province starting Thursday. The drugs do not cure the disease, but prolong life by preventing the onset of full-blown AIDS.
But even if the HIV infection rate were to stabilize today, the death rate would continue to rise for at least another five to 10 years, said Alan Whiteside, an economist at the University of KwaZulu-Natal in Durban.
It is the social, economic and political consequences of the oncoming wave of death and dying that may have the greatest impact on the future of democracy in South Africa.
"We simply don't yet know what the outcome will be," Whiteside said. "One possibility: You could get an unsocialized, uneducated, unloved and probably criminal generation growing up, a breakdown in social order, public services . . . at the extreme, a 'Blade Runner' world."
Or, he said, there is the possibility of "a national mobilization on the most basic levels around dealing with the crisis."
Compounded Problems
Sister Priscilla's clinic, about 15 miles southwest of Richards Bay, serves a sparsely populated area roughly 10 miles square. Between Christmas and the end of January, the number of children orphaned by AIDS in the area grew from 922 to 1,025. At the same time, the number of child-headed households visited by her staff increased from 372 to 420.
In the six years Sister Priscilla has worked at the Holy Cross Clinic -- the last two as the founding director of the Catholic mission's 40-bed AIDS hospice -- she has come to know the sounds of AIDS. From one ward room comes a shrill, whooping cry, punctuated by a dry, congested cough. Nomadla Dube, 7, is thirsty.
Her hollow eyes are round with fear and overflow with tears. "I want to go home," she cries out in Zulu. "Why do you keep me? Why? Why?"
Sister Priscilla calls for an aide to bring water. She leans over and whispers a few words of comfort, but she does not tell her the truth. The girl will never go home, even when she dies. "The mother is dead, the father is dead," Sister Priscilla said. "There is no home."
She opened the hospice because so many people dying from AIDS were being left in the sugar cane fields by their families for the clinic workers to find.
"People would come home from Durban and the other cities to die," Sister Priscilla said. "But relatives were not accepting them. They chased them away, or dumped them on the edge of the sugar cane plantations, and we were going around picking them up and bringing them here."
She ushers a visitor into a brightly lit room nearly filled with twin beds.
"This ward was to be used for couples," she said. "Sometimes you get couples dying at the same time." But these beds are rarely filled. "Most of the time the couples don't want to be together. They want to be separated. They blame each other if they are both positive."
The government has not said when the free drugs will arrive in places like Gingindlovu. But even if they came tomorrow, rural areas lack the infrastructure and trained staff to dispense and properly monitor the use of these sophisticated medications, she said.
"There are not enough workers, there are not enough nurses," said Sister Priscilla, who sits on the boards of local, national and international AIDS organizations. "It is a good first step, but it came too late, and even though it is late the government is not ready for it. The government finally opened its eyes and, boom, it was too late."
Politics, too, has conspired to make the AIDS belt perhaps the most neglected front in the government's belated response to the pandemic. Two years ago, the Global Fund, a nonprofit group based in Geneva, awarded $75 million to KwaZulu-Natal to fight AIDS. But the federal government held up the grant until last summer because the province had approached the Global Fund directly. Health Minister Manto Tshabalala-Msimang argued that the money should have been given to the national government and disbursed to all nine provinces.
KwaZulu-Natal is a poor province. Employment is sporadic and matched to the seasonal needs of the vast sugar plantations. A majority of the people here say they had gone without cash income "often" during the past year, according to the Post/Kaiser/Harvard survey. Six in 10 rural residents cook their meals over wood fires, and nearly half report that they "often" go to bed hungry. Nearly half still light their homes with candles. One in eight has running water inside the home; a flush toilet is a luxury enjoyed by three out of every 100 residents.
Poverty weakens those infected by HIV, hastening their deaths and confounding treatment plans. "Many people here take drugs for TB," Sister Priscilla said, referring to tuberculosis, the disease that is the leading cause of death for people with AIDS in South Africa. "But they stop taking them because their stomachs are empty and the drugs make them sick. There are many problems, one on top of the other. Addressing one is not enough."
Rations and Memories
One cool, overcast day, the grassy yard in front of the clinic was filled with nearly 100 older women in long, brightly colored dresses, each wearing a tightly wrapped scarf. These are the grandmothers whose children died of complications from AIDS. Now they raise their grandchildren. They had come to pick up a monthly food allotment.
Sister Priscilla called out two names, and the women made their way through the crowd. Sister Priscilla handed each of them a green booklet that resembled a passport, the identity documents of their dead children.
"We take the identification document and make a picture of the person's ID photo. Then we make up boxes -- memory boxes -- that contains the picture of the dead parent and some other things that were special to them, and we give it to their children so they have something of their parents," she said.
Some of the dying arrive at the hospice with nothing, not even identification documents. "In that case we give them a stone to hold before they die, and tell the children, 'Your mother held this stone.' "
After the identity documents were returned, clinic staff arranged food packets in neat piles on the concrete walkway and distributed them to the grandmothers. Ten kilograms of maize, or about 22 pounds; 10 kilograms of samp, a kind of coarsely ground hominy; five kilograms of pinto beans; one can of salmon; a box of instant milk; and an 18-inch-long bar of green soap.
"This is going to take care of me and my grandchildren," said Velephi Nzuza, 55, as she stood by a huge cloth bundle containing her food allocation. She is raising her granddaughters, age 9 and 13. "Without this, I am helpless. There would be nothing."
Graves and Grandchildren
A mile from the Holy Cross hospice, off the muddy red-dirt road that snakes between deep green sugar cane fields, three traditional mud huts hug the gentle slope that leads up to a small vegetable garden.
Through the garden choked with weeds and past the guava trees lie five simple graves overgrown with grass, the final resting places of Gertrude Ngobese's three sons and two daughters. Six grandsons and one granddaughter live with her, the children of Ngobese's second-born child, Sibongile, who died of AIDS in 1999. They range in age from 6 to 23 . Ngobese is not raising her grandchildren. They are caring for her.
"It's tough. Our grandmother is sick," said Skhumbuzo Nxumalo, the eldest and the leader of the family. He is shirtless, lean and handsome, and glances down shyly as he speaks through an interpreter in Zulu. "She can't speak properly. She can't do things on her own. We depend on our grandmother's pension, and the food parcels from the clinic."
None of the seven grandchildren has a job. A 7-month-old girl suckles at the breast of Pretty, Gertrude's 18-year-old unmarried granddaughter.
"I want to be employed and take care of my brothers and sister," Nxumalo said. "I used to get temporary work from our neighbor, planting sugar cane." No longer. "The guy giving me temporary work died of AIDS in October. All the people we depended on passed away."
Nxumalo cannot imagine a happy future for himself, his family or his country. "I don't see any future for this country. There are no jobs. We are sitting at home doing nothing. The government promised projects and things like that and they don't keep their promises." He laughs when asked whether he will vote in this year's presidential election. "What is it to vote when life is so bad?"
Nxumalo is shamed by the taunts of neighbors. He said his grandmother had complained to them "that she didn't have clothes because we took her money. . . . When we pass, the neighbors shout at us: Why are you taking your grandmother's money? If they feel that way, kill me, so I don't feel any more pain."
"That worries me," Pretty interjects, awkwardly cradling her nursing daughter. "If you die, who would take care of us? Who would take care of our grandmother?" The question hangs, unanswered, in the moist air.
There is good news today for the family. Pretty had gone to the Holy Cross Clinic to get the results of her latest HIV test.
"Negative," she said with a smile.
© 2004 The Washington Post Company