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In coming to grips with AIDS, the worst health calamity since the Middle Ages and one likely to be the worst ever, consideration inevitably turns to the numbers.
According to estimates from UNAIDS, an umbrella group for five U.N. agencies, the World Bank and the World Health Organization, 34.3 million people in the world have AIDS -- 24.5 million of them in sub-Saharan Africa. Nearly 19 million have died from AIDS, 3.8 million of them children under the age of 15.
Among the other statistics:
• 5.4 million new AIDS infections in 1999, 4 million of them in Africa.
• 2.8 million dead of AIDS in 1999, 85 percent of them in Africa.
• 13.2 million children orphaned by AIDS, 12.1 million of them in sub-Saharan Africa.
• Reduced life expectancy in sub-Saharan Africa from 59 years to 45 between 2005 and 2010, and in Zimbabwe from 61 to 33.
• More than 500,000 babies infected in 1999 by their mothers -- most of them in sub-Saharan Africa.
Finally, this: The bubonic plague is reckoned to have killed about 30 million people in medieval Europe. The U.S. Census Bureau projects that AIDS deaths and the loss of future population from the deaths of women of child-bearing age means that by 2010, sub-Saharan Africa will have 71 million fewer people than it would otherwise.
The numbers are staggering, but they do not begin to encompass the suffering and the dramas that put faces on the epidemic.
'We think we are animals'
One face belonged to Gugu Dlamini, a South African woman who admitted on television on World AIDS Day that she had AIDS. When she returned to her home, she was beaten to death by fellow villagers.
Another belongs to a Ugandan girl named Kevina who lost both parents and her aunts and uncles to AIDS. Although just 14, Kevina must care for four younger brothers, three younger sisters and her blind, 84-year-old grandfather. They have no money, food, health care or transportation. Their roof leaks and other villagers sometimes steal their firewood.
"The teacher calls us orphans," Kevina writes in a letter published by the United Nations Development Program, "but I don't want that name. Even other children don't want that name. We think we are animals."
Increasingly sophisticated treatments have cut the death AIDS death rate in the industrialized countries, but elsewhere the epidemic is gathering momentum.
Factors contributing to the spread of AIDS include poverty, ignorance, the prohibitive cost of AIDS drugs, an aversion to discussing sex and, some say, promiscuity.
"Promiscuity is a loaded word," says Shell. "I would say that AIDS is a result of unsafe sexual practices, and unguarded sexual behavior is the most important factor. Ignorance about reproductive health is the biggest factor [and it] is related to poverty and illiteracy. Ten percent of the Africans in my province have other sexually transmitted diseases ...."
'Most men are not tested'
Many men leave their rural homes to work in mines and on construction projects. This mobile work force and rapid urbanization has contributed to cities in which 40 to 50 percent of the population has AIDS.
In a document prepared for the U.N. Development Program, researcher Desmond Cohen writes that a 40 to 50 percent infection rate was once thought "wholly improbable."
Wars have also contributed to the problem.
Like migrant workers, truck drivers and young men, soldiers often visit "commercial sex workers," or prostitutes, 90 percent of whom are believed to have AIDS. Nigerian soldiers with the ECOMOG forces in Sierra Leone and Finnish soldiers serving as peacekeepers in Namibia took AIDS with them when they returned home.
Girls and women are often forced to have sex with men in male-dominated African cultures. In fact, says journalist Thomas, in some areas infected men "believe they can be cured by having sex with a virgin, and 12-year-old girls become infected."
The AIDS rate among women is much higher than among men, but as Shell points out "most men are not being tested."
Meanwhile, they unknowingly may be passing on the infection to African women. Compounding the problem, according to a U.N. study, is that 30 percent of young African women believe if a man looks healthy, he could not have AIDS.
Given the variables and incomplete reporting on the epidemic, it is difficult to assess its economic impact with any precision. But there have been estimates that the per capita income in most sub-Saharan countries has declined by 20 percent.
The American Foundation for AIDS Research noted in a research paper late in 1999 that 80 percent of those dying are workers between the ages of 20 and 50 -- workers in their prime.
"AIDS is slowly strangling many businesses and economies," the report said, "and in a global market everyone eventually suffers."
Many companies hire and train two and even three people to do the job of one person because AIDS is certain to fell some of them.
The epidemic is also responsible for the quadrupling of life insurance premiums in Zimbabwe, escalating health costs to Botswana companies by 500 percent and driving the health costs of a large Zambian company so high that they exceeded profits.
In Zimbabwe and Botswana, where roughly one of every four people have AIDS, the disease has cut sharply into population growth with negative consequences.
"The zero growth is coming because people are dying in their young adult years, not after leading full lives and then dying," says Karen Stanecki, chief of health studies for the U.S. Census Bureau.
"People are dying in the years when they're supposed to be most productive, and they won't be there to raise the next generation. Which means you'll have all these orphans and no one to raise them."
The danger of global consequences
One of the most alarming speculations is that by the year 2010 there will be 40 million AIDS orphans in Africa, most of whom will have grown up with little or no social structure.
As much as humanitarianism, it is this vision of lawlessness and chaos and their potential to destabilize the global economy that has fueled worldwide concern.
"If we don't work with the Africans themselves to address these problems," U.S. Ambassador to the United Nations Richard Holbrooke said in January 2000, "we will have to deal with them later when they will get more dangerous and more expensive."
Researchers are working on an AIDS vaccine, but such a medicine is still years away. In the meantime aggressive prevention programs can, and do, help.
A clever safe-sex campaign using catchy packaging and a suggestive slogan ("So Strong, So Smooth") turned condoms into a must-have item in Uganda. It also cut the AIDS rate from 15 percent to 9.7 percent. A vigorous program in Senegal has kept its infection rate at 2 percent
But African nations spend only $165 million a year to combat AIDS, and it all comes from the industrialized nations. James Wolfensohn, president of the World Bank, told the U.N. Security Council in January 2000 that an effective and comprehensive prevention program for sub-Saharan Africa would cost $2.3 billion a year.
To be effective prevention must be paired with investment that will create jobs, invigorate the educational system and pull the poor out of the "here and now" mentality that makes them susceptible to AIDS.
"Many of us used to think of AIDS as a health issue," Wolfensohn told the Security Council. "We were wrong. AIDS can no longer be confined to the health or social sector portfolios. AIDS is turning back the clock on development."
Says Vogl: "These countries have to make their economies grow. People who are trapped in poverty aren't going to do much about health care. If everything else in the country is falling to pieces, it is not going to have much effect."