Those of us living in the United States became used to the face of AIDS a generation ago. We learned to recognize the particular gauntness that characterized those who had been struck by it, and who would soon be taken away by it. And then, after years of people dying from this disease, we learned that people who had this terrible disease could be healed; not cured, for they still contained the viruses within their bodies, but they could live lives that were happy and meaningful - and long. The terror of AIDS subsided, becoming one of only many of the perils of modern life rather than one of the predominant ones.
But the trajectory of AIDS in South Africa (as well as in other parts of the developing world, has been very different. Even in the first years of the disease the manifestations of it tended to be worse in Africa, and the gap between Africa and the United States and Europe has only grown in the generation since, as Bond (1997) argues. This paper examines the impact that AIDS has had on South Africa, an impact that is based in the biology of the disease itself but far more in the social, cultural and economic conditions of this region of the world. For disease is never a purely physical phenomenon: The ways in we understand illness - and the ways in which we seek to combat it - are always a function of culture and belief, of economic resources, of history (Garrett 19).
The struggle against AIDS in South Africa reminds us of the cultural bases of both disease and health - and even more about how the practice of Western medicine is as culture (and so as rule-governed) as other systems of belief. This refutes the commonsense attitude that many readers might bring to the book, which dictates that the concepts of health and illness seem at first glance to be entirely biological constructs. After all, a person contracts tuberculosis not because she belongs to a certain religion or because he is a certain ethnicity but because a particular type of bacillus enters into her or his body and infects its human host. People get epilepsy because of a particular mis-wiring in their brains. Nothing could seem more straightforwardly objective and clear-cut and scientific. But in fact the picture is more complicated than this.
Health (and the absence of health, or sickness) is culturally constructed. Both concepts of sickness and perhaps even more ideas about health are in fact deeply culturally rooted in the specific belief systems of a given role and society. We get sick for a number of reasons - and through the invasion of our bodies by a number of parasites. This is as close to an objective Truth as any of us is likely to get. But health, and sickness (and what to do about either) is not only a matter of objective truth; belief matters at least as much as truth. It is impossible to understand the impact of AIDS in South Africa without remembering this, or without acknowledging this.
Part of understanding AIDS in South Africa (at least for those of us who are from other places in the world) is an understanding of traditional African beliefs - such as the fact that witchcraft is known by many Africans to cause unfortunate things to happen. This may be because witches themselves are evil and untrustworthy. Or it may be that the person involved has in fact done something bad and deserves to be cursed.
In order to understand something more of the cosmology of traditional Africans (and bearing in mind that we must treat their beliefs with as much respect as we do our own) let us sketch a hypothetical situation involving witchcraft. Let us assume that there is someone known to be greedy, selfish, and violent. One day this person becomes gravely ill after eating a newly discovered kind of berry. Everyone in the village comes to the conclusion that a) witchcraft exists; b) witches curse bad people; c) person X is a bad person; therefore d) a witch has placed a curse on this new fruit to teach person X not to be such a bad person anyone or at least to punish him.
Well that's silly, we are all tempted to say. Curses don't cause illness. Toxins and microbes do.
Well, possibly. But let us look at the syllogism that Westerner might invoke in the same situation. a) Toxins and microbes exist; b) toxins and microbes hurt people; c) person X is a person and so can be hurt; therefore d) person X has eaten a fruit that is either poisonous or infectious.
But you may say that the two cases are entirely different, that poisons are real, for example, and curses are not. There are two rejoinders to this. Certainly most Americans believe that in fact poisons are real. But, on the other hand, most of them have no personal expertise in detecting them as I am not a chemist. If someone points out a fruit to most people and tells them that it is poisonous, they have to take this on faith.
There is no significant difference between a person's accepting that a particular fruit is poisonous just because the person who says so has an advanced degree in chemistry and a villager learning about curses from an elder. Both systems of thought require that lay people - whether non-scientists or non-witches, take a great deal on faith from experts.
The mixture of traditional understanding of cause and effect (such as in our hypothetical case above) with Western medical concepts is part of the story of AIDS in South Africa - along with the political and economic situation of the country. All of these will be explored in greater detail below.
The importance of designing and instituting an effective AIDS prevention program in South Africa is imperative because of the number of people already sick with the disease, its probably spread, and the terrible costs to South African society that will result from the pandemic unless significant social intervention occurs. South Africa has more HIV-positive people than there are in any country in the world. The following statistics give us some sense of how terrible the pandemic could (and in fact is likely to) become in South Africa:
Estimated HIV Infected: 4.8 million
Estimated 1999 AIDS Deaths: 250,000
Estimated AIDS Orphans: 420,000
11% of South Africans are HIV-infected; by 2010 adult HIV prevalence could reach 25%.
Daily estimates of 1,600 people with new HIV infection; two-thirds of them aged 15 to 20.
By 2008, 1.6 million children will have been orphaned by AIDS.
South Africa has a well-developed health infrastructure relative to other African nations, and there is a substantial amount of international and donor interest in the country.
In 2005 the population is expected to be 16% lower than it would have been in the absence of AIDS. By 2015 population loss to AIDS-related deaths will be 4.4 million.
In 1998 South Africa had approximately 100,000 AIDS orphans, and by 2008, 1.6 million children will have been orphaned by AIDS.
An estimated 50% of all tuberculosis patients are co-infected with HIV. In some hospitals in South Africa, the HIV prevalence in tuberculosis patients is higher than 70% (http://www.cdc.gov/nchstp/od/gap/countries/south_africa.htm).
The figures above give a good sense of the seriousness of the disease in South Africa in medical terms. However, even these figures fail to convey the true cost that South Africa will have to bear over the next generation as a result of the pandemic:
HIV / AIDS will create significant economic costs to businesses, although the long-term macro-economic impact is likely to be limited to a Gross Domestic Product (GDP) growth rate reduction of about 1% per annum (http://www.aids.org.za/,Lamont 2002)
HIV / AIDS care will become a substantial part of health care spending, thus substantially limiting the ability of the country to pay for other vital health services, including especially the prevention and treatment of tuberculosis and maternity care (http://www.aids.org.za/).
South African women, who already perform more than half of the work of the nation (http://www.aids.org.za/,Nessman 2002; Khan 2003)
The HIV epidemic will produce large numbers of AIDS orphans (by 2005 there will be nearly a million children under the age of 15 who will have lost their mothers to AIDS) (http://www.aids.org.za/)
Education will be affected through staff becoming infected and through increasing needs of affected and infected children. The need to educate children, in addition to becoming more pragmatically difficult, may well seem to be less important to a nation that feels that its future has been fundamentally compromised (McGreal 2002; "AIDS against AIDS" 2003).
The ability of the nation's welfare system to help those debilitated by AIDS, AIDS orphans the elderly who no longer have adult children to care for them will be severely tested; in the likely event that the government is unable to provide needed social services…