Instead, I spent the ceremony thinking about viral antigens, cross-reactionsand other mysteries of what Sowetans call H.I.Vilakazi, the scourge of thedeadly three letters. Then, midway through the proceedings, the pastorbroke my reverie; Perhaps the visitors would like to say something? I roseto my feet, straightened my tie and prepared to speak my mind, but couragefailed me, so I mumbled a few platitudes instead. "It is a heartbreak thatAdelaide was taken so young," I said. "She bore terrible suffering withenormous dignity," I said. "We will always remember her as she appears inthat picture," I concluded, nodding toward a framed portrait of a wistfulyoung woman with huge doe eyes and haunting cheekbones like MarleneDietrich's. Adelaide wanted to be a model. She never made it. I extended mycondolences to the family and sat down again.
It wasn't the eulogy Adelaide deserved, but then it wasn't the right timeor place for a great cry of rage and confusion, either. But now themourning is done, and there are things that must be said.
My first mistake
Africa's era of megadeath dawned in the fall of 1983, when the chief ofinternal medicine of a hospital in what was then Zaire sent a communique toAmerican health officials, informing them that a mysterious disease seemedto have broken out among his patients. At the time, the United States wasbeing convulsed by its own weird health crisis. Large numbers of gay menwere coming down with an unknown disease of extraordinary virulence,something never seen in the West before. Scientists called it GRID, anacronym for Gay-Related Immune Deficiency. Political conservatives and holymen called it God's vengeance on sinners. American researchers were thusintrigued that a similar syndrome had been observed in heterosexuals inAfrica. A posse of seasoned disease cowboys was convened and sent forth toinvestigate.
On October 18th, 1993, they walked into Kinshasa's Mama Yemo Hospital, ledby Peter Piot, 34, a Belgian microbiologist who had been to the institutionyears earlier, investigating the first outbreak of Ebola fever. A changewas immediately apparent. "In 1976, there were hardly any young adults inorthopedic wards," Piot told a reporter. "Suddenly - boom - I walked in andsaw all these young men and women, emaciated, dying." Tests confirmed hisworst apprehensions: The mysterious new disease was present in Africa, andits victims were heterosexual. When researchers started looking for thenewly identified human immunodeficiency virus, it turned up almosteverywhere - in eighty percent of Nairobi prositutes, thiry-two percent ofUgandan truck drivers, forty-five percent of hospitalized Rwandan children.Worse, it seemed to be spreading very rapidly. Epidemiologists plottedfigures on graphs, drew lines linking the data points and gaped in horror.The epidemic curve peaked in the stratosphere. Scores of millions - maybemore - would die unless something was done.
These prophecies transformed the destiny of AIDS. In 1983, it was a fairlyrare disease, confined largely to the gay and heroin-using subcultures ofthe West. A few years later, it was a threat to all of humanity itself. "Westand nakedly before a pandemic as mortal as any there has ever been,"World Health Organization chief Halfdan Mahler told a press conference in1986. Western governments heeded his anguished appeal for action. Billionswere invested in education and prevention campaigns. According to theWashington Post, impoverished AIDS researchers suddenly had budgets thatoutstripped their spending capacity. Nongovernmental AIDS organizationssprang up all across Africa - 570 of them in Zimbabwe, 300 in South Africa,1,300 in Uganda. By 2000, global spending on AIDS had risen to manybillions of dollars a year, and activists were urging the commitment ofmany billions more, largely to counter the apocalypse in Africa, where 22million were said to carry the virus and 14 million to have died of it.
And this is about where I entered the picture - July 2000, three monthsafter South African President Thabo Mbeki announced that he intended toconvene a panel of scientists and professors to re-examine the relationshipbetween the human immunodeficiency virus and AIDS. Mbeki never exactly saidAIDS doesn't exist, but his action begged the question, and theimplications were mind-bending. South Africa was said to have more HIVinfections (4.2 million) than any other country on the planet. One in fiveadults were already infected, and the toll was rising daily. As his wordssank in, disbelief turned to derision.
"Ludicrous," said the Washington Post.
"Off his rocker," said the Spectator.
"A little open-mindedness is fine," said Newsday. "But a person can be soopen-minded, his brains can fall out."
The whole world laughed, and I rubbed my hands with glee: South Africa wasback on the world's front pages for the first time since the fall ofapartheid; fortune awaited the man of action. I went to see a friendwho happens also to be an AIDS epidemiologist. He was so enraged by what hecalled the "genocidal stupidity" of Mbeki's initiative that he'd left workand gone home, where I found him slumped in depression. "Hey," I said, snapout of it. Let's make a deal." And so we did: He'd talk, I'd type, andtogether we'd tell the inside story of Thabo Mbeki's AIDS fiasco. All thatremained was to consider to consider the evidence that had led our leaderastray.
According to newspaper reports, Mbeki had gleaned much of what he knew fromthe Web, so I revved up the laptop and followed him into the virtualunderworld of AIDS heresy, where renegade scientists maintain Web sitesdedicated to the notion that AIDS is a hoax, dreamed up by a diabolicalalliance of pharmaceutical companies and "fascist" academics whose onlyinterest is enriching themselves. I visited several such sites, noted whatthey had to say, and then turned to Web sites maintained by universitiesand governments, which offered crushing rebuttals. Can't say I understoodeverything, because the science was deep and dense, but here's the gist:
Look at AIDS from an African point of view. Imagine yourself in a mud hut,or maybe a tin shack on the outskirts of some sprawling city. There'ssewage in the streets, and refuse removal is nonexistent. Flies andmosquitoes abound, and your drinking water is probably contaminated withfeces. You and your children are sickly, undernourished and stalked bydiseases for which you're unlikely to receive proper treatment. Worse yet,these diseases are mutating, becoming more virulent and drug-resistant.Minor scourge such as diarrhea and pneumonia respond sluggishly toantibiotics. Malaria now shrugs off treatment with chloroquine, which isoften the only drug for it available to poor Africans. Some strains oftuberculosis - Africa's other great killer - have become virtuallyincurable. Now atop all this is AIDS.
According to what you hear on the radio, AIDS is caused by atiny virus that lurks unseen in the blood for many years, only to emerge indeep disguise: a disease whose symptoms are other diseases, like TB, forinstance. Or pneumonia. Running stomach, say, or bloody diarrhea in babies.These diseases are not new, which is why some Africans have always beenskeptical, maintaining that AIDS actually stands for "American Idea forDiscouraging Sex." Others say nonsense, the scientists are right, we're allgoing to die unless we use condoms. But condoms cost money and you have none,so you just sigh and hope for the best.
Then one day you get a cough that won't go away, and youstart shedding weight at an alarming rate. You know these symptoms. In thepast, you could take some pills and they would usually go away. But themedicines don't work anymore. You get sicker and sicker. You wind up in theAIDS ward.
The orthodox scientists, if they could see you lying there,would say your immune system has been destroyed by HIV, allowing thetuberculosis (or whatever) to run riot. The dissidents would say no way - thevirus is a harmless creature that just happens to accompany immune-systembreakdown caused by other factors, in this case a lifetime of hunger andexposureto tropical pathogens.
Incensed by this, the orthodoxy whistles up a truckload ofstudies from all over Africa showing that HIV-positive hospital patients die atastronomical rates relative to their HIV-negative counterparts. The dissidentsclaim to be unimpressed. This proves nothing, they say except that dyinghospital patients carry the virus.
The orthodoxy grits its teeth. There's only one way to crushthese rebels, and that's to show that AIDS is a new disease that has caused amassive increase in African mortality, which is of course the truth as we knowit: 22 million Africans infected, with 14 million more already dead fromit.
These frightening numbers were all that mattered, it seemedto me. Once they were shown to be accurate, further debate would be renderedobscene, and Thabo Mbeki would be guilty as charged, a fool who'd allowed himselfto be swayed by a tiny band of heretics universally dismissed as wackos, fringe lunaticsand scientific psychopaths. So I set out to confirm the death toll. Just that. I thought itwould be easy - a call or two, maybe a brief interview. I picked up the phone. It was myfirst mistake.
A Forbidden Thought
There was a time when I imagined medical research as an idealized endeavor,carried out by scientists interested only in truth. Up close, it turns out to be much likeany other human enterprise, riven with envy, ambition and the standard jockeying for position.Labs and universities depend on grants, and grantmaking is fickle, subject to the vagariesof politics and intellectual fashion, and prone to favor scientists whose work grips thepopular imagination. Every disease has champions who gather the data and proclaim thethreat it poses. The cancer fighters will tell you that their crisis is deepening, and moreresearch money is urgently needed. Those doing battle with malaria make similar pronouncements,as do those working on TB, and so on, and so on. If all their claims are added together, youwind up with a theoretical global death toll that "exceeds the number of humans who dieannually by two- to threefold," said Christopher Murray, a World Health Organization director.
Malaria kills around 2 million humans a year, roughly the same number as AIDS, but malariaresearch currently gets only a fraction of the resources devoted to AIDS. Tuberculosis(1.7 million victims a year) is similarly sidelined, to the extent that there were no new TBdrugs in development at all as of 1998. AIDS, on the other hand, is replete, employing anestimated 100,000 scientists, sociologists, caregivers, counselors, peer educators and stagersof condom jamborees. Until the attacks of September 11th diverted the world's anxieties(and charity dollars), the level of funding for AIDS grew daily as foundations, governmentsand philanthropists such as Bill Gates entered the field, unnerved by the bad news, whichusually arrived in the form of articles describing AIDS as a "merciless plague" of "biblicalvirulence," causing "terrible depredation" (as Time recently put it) among the world's poorestpeople.
These stories all originate in Africa, but the statistics that support them emanate from thesuburbs of Geneva, where the World Health Organization has its headquarters. Technically employed by the United Nations, WHO officials are the world's disease police, dedicated to eradicating illness. They crusade against old scourges, raise the alarm against new ones,fight epidemics, and dispense grants and expertise to poor countries. In conjunction with UNAIDS (the joint United Nations Programme on HIV/AIDS, based at the same Geneva campus), the WHO also collects and disseminates information about the AIDS pandemic.
In the West, the collection of such data is a fairly simple matter: Almostevery new AIDS case is scientifically verified and reported to governmenthealth authorities, who inform the disease police in Geneva. But AIDSmostly occurs in Africa, where hospitals are thinly spread, understaffedand often bereft of the laboratory equipment necessary to confirm HIVinfections. How do you track an epidemic under these conditions? In 1985,the WHO asked experts to hammer out a simple description of AIDS, somethingthat would enable bush doctors to recognize the symptoms and start countingcases, but the outcome was a fiasco - partly because doctorsstruggled to diagnose the disease with the naked eye, but mostly becauseAfrican governments were too disorganized to collect the numbers and sendthem in. Once it become clear that the case-reporting system wasn'tworking, the WHO devised an alternative, by which Africa's AIDS statisticsare now primarily based.
It works like this: On any given morning anywhere in sub-Saharan Africa,you'll find crowds of expectant mothers ling up outside government prenatalclinics, waiting for a routine checkup that includes the drawing of a bloodsample to test for syphilis. According UNAIDS, "anonymous blood specimensleft over from these tests are tested for antibodies to HIV," a ritual thatusually takes place once a year. The results are fed into a computer modelthat uses "simple back-calculation procedures" and knowledge of "thewell-known natural course of HIV infection" to produce statistics for thecontinent In other words, AIDS researchers descend on selected clinics,remove the leftover blood samples and screen them for traces of HIV Theresults are forwarded to Geneva and fed into a computer program calledEpi-model: If a given number of pregnant women are HIV-positive, theformula says, then a certain percentage of all adults and children arepresumed to be infected, too. And if that many people are infected, itfollows that a percentage of them must have died. Hence, when UNAIDSannounces 14 million Africans have succumbed to AIDS, it does not mean 14million infected bodies have been counted. It means that 14 million peoplehave theoretically died, some of them unseen in Africa's swamps,shantytowns and vast swaths of terra incognita. ♥ ☼ ♥
You can theorize at will about the rest of Africa and nobody will ever bethe wiser, but my homeland is different - we are a semi-industrializednation with a respectable statistical service. "South Africa," says IanTimaeus, London School of Hygiene and Tropical Medicine professor andUNAIDS consultant "is the only country in sub-Saharan Africa wheresufficient deaths are routinely registered to attempt to produce nationalestimates of mortality from this source." He adds that, "coverage is farfrom complete," but there's enough of it to be useful - around eight of tendeaths are routinely registered in South Africa, according to Timaeus,compared to about 1 in 100 elsewhere below the Sahara.
It therefore seemed to me that checking the number of registered deaths inSouth Africa was the surest way of assessing the statistics from Geneva, soI dug out the figures. Geneva's computer models suggested that AIDS deathshere had tripled in three years, surging from 80,000-odd in 1996 to 250,000in 1999. But no such rise was discernable in total registered deaths, whichwent from 294,703 to 343,535 within roughly the same period. Thediscrepancy was so large that I wrote to make absolutely sure I hadunderstood these numbers correctly. Both parties confirmed that I had, andat that exact moment, my story was in trouble. Geneva's figures reflectedcatastrophe. Pretoria's figures did not. Between these extremes lay a grayarea populated by local experts such as Stephen Kramer, manager ofinsurance giant Metropolitan's AIDS Research Unit, whose own computer modelshows AIDS deaths at about one-third Geneva's estimates. But so what? SouthAfrican actuaries don't get a say in this debate. The figures you see inyour newspapers come from Geneva. The WHO takes pains to label thesenumbers estimates only, not rock-solid certainties, but still, these areestimates we all accept as the truth.
But you don't want to hear this, do you? Nor did I. It spoiled the plot, soI tried to ignore it. Since it was indeed true that the very large numbersof South Africans were dying, then the nation's coffin makers had to belaboring hard to keep pace with growing demand. One newspaper account Ifound told of a company called Affordable Coffins, purveyor of cheapcardboard caskets, which had more orders than it could fill. But the firmwas barely two months old when the story ran, and two rival entrepreneurswho launched similar products a few years back had gone under. "Peopleweren't interested." said a dejected Mr. Rob Whyte. "They wanted coffinsmade of real wood."
So I called the real-wood firms, three industrialists who manufacturedcoffins on an assembly line for the national market. "It's quiet," saidKurt Lammerding of GNG Pine Products. His competitors concurred - businesswas dead, so to speak.
"It's a fact," said Mr. A. B. Schwegman of B&A Coffins. "If you go on whatyou read in the papers, we should be overwhelmed, but there's nothing. Sowhat's going on? You tell me."
I couldn't, although I suspected it might have something to do with race.Since the downfall of apartheid, in 1994, illegal backyard funeral parlorshave mushroomed in the black townships, and my sources couldn't discountthe possibility that these outfits were scoring their coffins from theunderground economy. So, I called a black-owned firm, Mmabatho Coffins, butit had gone out of business, along with some others I tried calling. Thiswas getting seriously weird. The death rate had almost doubled in the pastdecade, according to a recent story in South Africa's largest newspaper."These aren't projections," said the Sunday Times. "These are the facts."And if the facts were correct, I thought, someone somewhere had to beprospering in the coffin trade.
Further inquiries led me to Johannesburg's derelict downtown, where a giantmultistory parking garage has recently been transformed into a vast warrenof carpentry workshops, each housing a black carpenter, set up in businesswith government seed money. I wandered around searching for coffin makers,but there were only two. Eric Borman said business was good, but he was amaster craftsman who made one or two deluxe caskets a week and seemed toresent the suggestion his customers were the sort of people who died ofAIDS. For that, I'd have to talk to Penny. Borman pointed, and off I went,deeper and deeper into the maze. Penny's place was locked up and deserted.Inside, I saw unsold coffins stacked ceiling-high, and a forlorn CLOSEDsign hung on a wire.
At that moment, a forbidden thought entered my brain. This may sound crazyto you, thousands of miles away, but put yourself in my shoes. You live inAfrica - OK , in the post-colonial twilight of Johannesburg's once-whitesuburbs, but still, close enough to the AIDS front line. For years, expertstell you that the plague is marching down the continent, coming evercloser. At first nothing happens, but there dawns a day when the HIVestimates start rising around you, and by 2000 the newspapers are tellingyou that one in five adults on your street is walking dead.
This has to be true, because it's coming from experts,so you start looking for evidence. Laston, the gardener at Number 10, issuspiciously thin, and has a hackingcouch that won't go away. On the far side of the golf course, Mrs. Smithhas just buried her beloved servant. Mr. Beresford's maid has just died,too. Your cousin Lenny knows someone who owns a factory where all theworkers are dying. Your newspapers are regularly predicting that theeconomy will surely be crippled, and schooling may soon collapse because somany teachers have died.
But then you find yourself staring into Penny's failed coffin workshop andyou think, Jesus, maybe something is wrong here...
Is this likely? Look, I believe that AIDS exists and it's killing Africans.But as many as all the experts tell us? Hard to say. In my suburb, I canassure you, people's brains are so addled by death propaganda that weautomatically assume almost everyone who falls seriously ill or dies hasAIDS, especially if they're poor and black. But we don't really know forsure, and nor do the sufferers themselves, because hardly anyone has beentested. "What's the point?" asks Laston, the ailing gardener. He knowsthere's no cure for AIDS, and no hope of obtaining life-extendinganti-retrovirals. Last winter, he came down with a bad cough, and everyonesaid it was AIDS, but it wasn't - come summer, Laston got better. ThenStanley the bricklayer became our street's most likely case. Stanmaintained he had a heart condition, but behind his back, everyone waswhispering, "Oh, my God, it's AIDS." But was it? We had no idea. We were playing a game, driven by hysteria.
No one wanted to hear this. Worried friends slipped newspaper clippingsinto my mailbox: CEMETERY OVERFLOWS....HOSPITALS OVERWHELMED....PRISONDEATHS UP 535 PERCENT. I checked out all the evidence, but often there wassome other possible explanation, like cut-price burial plots or a TBepidemic in the overcrowded jails or a funding crisis in governmenthospitals. After months of this, even my mother lost patience. "Shut up!"she snapped. "They'll put you in a straitjacket." Mother knows best, but Ijust couldn't get those numbers out of my head: 294,703 registered deathsin 1996, 343,535 four years later. I called my friend the AIDSepidemiologist and said, "Listen, I am beset by demons and heresies, can younot save me?" So we had lunch, and I aired my doubts, whereupon he pointedin the direction where truth lay, and I set out to find it.
A Bell is Rung
And here we are on a hilltop on the equator, overlooking the landscapewhere Africa's first recorded outbreak of AIDS took place. It's a villagecalled Kashenye, which lies on the border between Uganda and Tanzania.close to where the Kagera River flows into Lake Victoria. In 1979 orthereabouts, according to local legend, a trader crossed the river in acanoe to sell his wares in Kashenye. Business done, he bought some beersand relaxed in the company of a village girl. Some time later, she fellvictim to a wasting disease that refused to respond to any knownmedication, Western or tribal.
Not long after, according to Edward Hooper in his book Slim, a similardrama unfolded in Kasensero, a fishing village over on the Uganda side ofthe river. There the first victim was also a local girl, and the agent ofinfection was said to have been a visitor from Kashenye. In due course,several more citizens of Kashenye contracted the wasting disease. Theirneighbors cried foul, accusing Kashenye of putting a hex on them. Kashenyeresponded with similar allegations. Soon, villagers on both banks of theriver were discarding objects brought from the other side, believing themto be bewitched. But nothing helped. By 1983, the contagion was in all thecities on the Western shore of Lake Victoria. Within a few years theregion became known as the epicenter of Africa's AIDS epidemic, andUgandan president Yoweri Museveni was predicting that "apocalypse" wasimminent.
His prophesy was based largely on testing done among small groups ofhigh-risk subjects. Many factors were unknown, however, including the trueextent of infection in the general populace, the rate at which it wasspreading, the speed at which it killed. To formulate an effective battleplan, AIDS researchers desperately needed more data in these areas.
They cast around for a place to study, and lit on the Masaka district inUganda, a ramshackle area just west of Lake Victoria and probably 100 milesnorth of Ground Zero. The rate of infection there among adults was notparticularly high - just more than eight percent - but there were otherconsiderations making it a good place to study: The district waspolitically stable, and there was an international airport three hoursaway. In 1989, a Dutch epidemiologist named Daan Mulder began to lay thegroundwork for what would ultimately become the longest and most importantstudy of its kind in Africa.
Assisted by an army of of field workers, Mulder drew a circle aroundfifteen villages outside Masaka and proceeded to count every resident. Thenhe took blood from all those who were willing - 8,833 out of 9,777inhabitants - screened it for HIV infections and sat back to see whathappened. Every household was visited at least once a year, and every deathwas noted and entered into Mulder's database, along with the deceased's HIVstatus.
The first results were published in 1994, and they were devastating. TheHIV-infected villagers of Masaka were dying at a rate fifteen times higherthan their uninfected neighbors. Young adults with the virus in theirbloodstream were sixty times more likely to perish. Overall, HIV-relateddisease accounted for a staggering forty-two percent of all deaths. TheAIDS dissidents were crushed, HIV theory was vindicated. "If there are anyleft who will not even accept [this]," commented the U.S. Centers forDisease Control upon the release of the results, "their explanation of howHIV-seropositivity leads to early death must be very curious indeed."
Clearly, only a fool would second-guess such powerful evidence, so I justvisited the villages where Mulder's work was done, verified what he'd foundand headed back toward the airport, my story about Mbeki's stupidity backon track. But on my way I spent an hour or two in Uganda's StatisticsOffice, and what I learned there changed things yet again.
In 1948, Uganda's British rulers attempted a rough census in the Masaka areaand concluded that the annual death rate was "a minimum of twenty-five tothirty per thousand." A second census, in 1959, put the figure attwenty-one deaths per thousand. By 1991, it had fallen to sixteen perthousand. Enter Daan Mulder with his blood tests, massive funding andarmies of field workers. He counted every death over two years, and thenfive, and here is his conclusion: The crude annual death rate in Masaka, inthe midst of a horrifying AIDS plague, was 14.6 per thousand - the lowestever measured.
I was relieved to discover that there was another possible interpretationof these statistics. Daan Mulder's work began at a time when Uganda wasemerging from two decades of terror and chaos. Doctors had fled thecountry, hospitals had collapsed and nobody kept track of mortality trendsin the dark years of the Seventies and Eighties. According to Britishstatistician Andrew Nunn, one of Mulder's collaborators, disease-relatedrates must have fallen to all-time low levels in the Seventies, when no onewas counting, and then surged massively with the advent of AIDS around1980.
"In fact," says Nunn, "evidence suggests it's epidemic." (Mulder himselfcannot be asked to explain his findings - he has since died ofcancer.)
Nunn's explanation may be so, but the same can't apply toneighboring Tanzania, which embarked in 1992 on an even larger mortalitystudy. Like Mulder's, it was funded by the British government and supportedby scientists from the British universities. The Adult Morbidity andMortality Project recruited 307,912 participants, each of whom was visitedat least once a year in the next three years and questioned about recentdeaths or disease. The final results were rather like Masaka's: AIDS wasthe leading reported cause of adult mortality, but the average death ratein the communities studied was 13.6 per thousand - ten percent lower thanthe death rate measured in the census of 1988, which was rated "close to100 percent" complete by Dr. Timaeus, the UNAIDS consultant. Timaeus is aleading authority on African mortality in th AIDS era, and it was to himthat my difficult question ultimately fell.
Professor Timaeus," I said in his London office, "this study appears toshow that there was no increase in the death rate between 1988 and 1995, inthe heart of Tanzania's AIDS epidemic."
He shrugged. "This survey covered only part of the country," he said.
"True," I said, "but a fairly large part, with hundreds of thousands ofparticipants."
"But were they representative?" he countered.
I had no idea. Timaeus smiled and said, "I think this is themore critical evidence."
Whereupon he produced a sheath of graphs and papers and laid them on thetable. There was, he said, a "regrettable" lack of knowledge aboutmortality trends in Africa, attributable to "inertia," indifference and acrippling lack of up-to-date data. These factors bedeviled the demographer,but Timaeus said he knew of several ways around them, most dramatic ofwhich is the so-called sibling-history technique of mortality estimation.It works like this:
Since 1984, researchers financed by the U.S. Agency for InternationalDevelopment have conducted detailed health interviews with severalthousand mothers in developing countries worldwide. Among the questions putto them are these: How many children did your mother have? How many arestill alive? When did the others die? Timaeus realized that close analysisof the answers might reveal trends that were failing to show up elsewhere.He set to work, and published the results in the journal AIDSin 1998. "In just six years (1989-1995) in Uganda," he wrote, "men's deathrates more than doubled." Similar trends were revealed in Tanzania, hereported, where "men's deaths apparently rose eighty percent" in the sameperiod.
Again, this seemed to settle the matter, but again, there were puzzlingcomplications. For a start, Timaeus' study coincided with Daan Mulder'sepic mortality study, which ran for seven years without detecting any significant change in the death rate. The same is true ofTanzania's giant adult-mortality survey, which fell in the heart of theperiod when Timaeus says male mortality was surging upward but which failedto document any such thing.
Could there have been some problem with Timaeus' data? Kenneth Hill is theJohns Hopkins university demographer who helped conceive thesibling-history technique. Recently, he and his team embarked on aworldwide evaluation of its performance in the field, to check on itsaccuracy. Last year, an article co-authored by Hill reported that themethod was prone to something called, "downward bias" - meaning that peopleremember recent deaths pretty clearly, but those from years back tend tofade. According to the article, which appeared in Studies inFamily Planning, this usually leads to a false impression of risingmortality rates as you near the present. This has happened even in countieswhere there was little or no AIDS. In Namibia, for instance, the siblingmethod detected a 156 percent rise in the fourteen years prior to 1992,when the country's HIV infection rate ranged from zero to one percent."This lack of precision," Hill and his associate wrote, "precludes the useof these data for trend analysis."
"I disagree," said Timaeus, who believes they got their math wrong. NeitherHill or any members of his team wanted to respond on the record, but I drewone of them into a conversation on another subject.
"Do you accept the high levels of HIV infection being reported by Geneva?"I asked.
"I don't have much faith," he said. "It's essentially a modeling exercise,and the exercise has always seemed to have a political dimension."
That rung a bell. I was living in Los Angeles in 1981, when the very firstcases of GRID were detected. I knew men who were stricken, and Isympathized entirely with their desperation. They wanted government actionand knew there would be little as long as the disease was seen as a scourgeof queers, junkies and Haitians. So they forged an alliance with powerfulfigures in science and the media and set forth to change perceptions, armed inter alia with potent slogans such as "AIDS is anequal-opportunity killer" and "AIDS threatens everyone." Madonna, LizTaylor and other stars were recruited to drive home the message to thestraight masses: AIDS is coming after you, too.
These warnings were backed backed up by estimates such as the one issued bythe CDC in 1985, stating that 1.5 million Americans were alreadyHIV-infected, and the disease was spreading rapidly. Dr Anthony Fauci, nowhead of the National Institute of Allergic and Infectious diseases,prophesied that "2 to 3 million Americans would be HIV-positive within adecade. Newsweek's figures in a 1986 article were at leasttwice as high. That same year, Oprah Winfrey told the nation that "by 1990one in five" heterosexuals would be dead of AIDS. As the hysteriaintensified, challenging such certainties came to be dangerous. In 1988 NewYork City Health Commissioner Stephen C. Joseph reviewed the city's estimateof HIV infections, concluded that the number was inaccurate and halved it,from 400,000 to 200,000. His office was invaded by protesters, his lifethreatened. Demonstrators tailed him to meetings, chanting, "Resign,resign!"
In hindsight, Dr. Joseph's reduced figure of 200,000 might itself be anexaggeration, given that New York City has recorded a total of around120,000 AIDS cases since the start of the epidemic two decades ago. In1997, a federal health official told the Washington Post thatby his calculation, the true number of HIV infections in the United Statesback in the mid-Eighties must have been around 450,000 - less thanone-third of the figure put forth at the time by the CDC.
If the numbers could be gotten so wrong in America, what are we to make ofthe infinitely more dire death spells cast upon the developing world? In1993, Laurie Garrett wrote in her book The Coming Plague thatThailand's AIDS epidemic was "moving at super-sonic speed." It has stalledat just below two percent, according to UNAIDS. In 1991 All India Instituteof Medical Sciences official Vulmiri Ramalingaswami said AIDS in India "wassitting on top of a volcano," but infection levels there have yet to crestone percent. The only place where the AIDS apocalypse has materialized inits full and ghastly glory is in Geneva's computer models of the Africanpandemic, which show millions dead and far worse coming.
Why Africa, and Africa only? I now know a possible reason. Read on.
"Crap!" An Expert Declares
In many ways, the story of AIDS in Africa is a story of the gulf between rich and poor, the privileged and the wretched. Here is one way of calibrating the abyss.
Let's say you live in America, and you committed an indiscretion with drugs and needles or unprotected sex a few years back, and now find yourself plagued by ominous maladies that won't go away. Your doctor frowns and says you should have an AIDS test. She draws a blood sample and sends it to a laboratory, where it is subjected to an exploratory ELISA (enzyme-linked immunosorbent assay) test. The ELISA cannot detect the virus itself, only the antibodies that mark its presence. If your blood contains such antibodies, the test will "light up," or change color, whereupon the lab tech will repeat the experiment. If the second ELISA lights up, too, he'll do a confirmatory test using the more sophisticated and expensive Western Blot method. And if that confirms the infection, the Centers for Disease Control recommends that the entire procedure be repeated using a new blood sample, to put the outcome beyond all doubt.
In other words, we're talking six tests in all, doubly confirmed. Such a protocol is probably foolproof, but as you draw away from the First World, health-care standards decline and people grow poorer, meaning that confirmatory tests become prohibitively expensive. In Johannesburg, for instance, a doctor in private practice will typically want three consecutive positive ELISAs before deciding that you are HIV-positive. But his counterpart in a government-sponsored testing center has to settle for two ELISA tests.
In the annual pregnancy-clinic surveys on which South Africa's terrifying AIDS statistics are based, the protocol is one ELISA only, unconfirmed by anything. In America one ELISA means almost nothing. "Persons are positive only when they are repeatedly reactive by ELISA and confirmed by Western Blot," says the CDC. The companies that manufacture ELISAs agree: The tests must be confirmed by other means. "Repeatedly reactive specimens may contain antibodies" to HIV, one firm's literature says, "Therefore additional, more specific tests must be run to verify a positive result."
In parts of Africa, however, at least for the pupose of data-gathering, such precautions are deemed unnecessary. That's partly because the World Health Organization itself actually evalutates commercial HIV tests as they come on the market. In these trials, new tests are measured against a panel of several hundred blood samples from all over the world. Some of the samples are HIV-positive, some are not. The ELISAs are tested to make sure they can tell which are which. Among the scores of brands evaluated throughout the years, a handful have proved to be useless. But those manufactured by established biotechnology corporations usually pass with flying colors, typically scoring accuracy rates close to perfect.
In South Africa, such outcomes were often cited in furious attacks on President Mbeki. "HIV tests such as the latest-generation ELISA are now more than ninety-nine percent accurate." reported the Weekly Mail and Guardian. The tests have confidence levels of 99.9 percent, said professor Malegapuru Makoba, head of the Medical Research Council. Science had spoken, and science was unanimous: The tests were fine, and Mbeki was a fool, according to the Weekly Mail, "trying to be a Boy's Own basement lab hero of AIDS science."
It was a good line. I laughed, too, but there came a moment when it ceased to be funny.
My education in the complexities of the ELISA test started when I came across an article in a scientific journal published last year. It told a story that began in 1994, when researchers ran HIV tests on 184 high-risk subjects in a South African mining camp. Twenty-one of the subjects came up positive or borderline positive on at least one ELISA. But the results were confusing: A locally manufactured test indicated seven, but different people in almost every case. A French test declared fourteen were infected.
It seemed something was confounding the tests, and the prime suspect was plasmodium falciparum, one of the parasites that causes malaria: Of the twenty-one subjects who tested positive, sixteen had had recent malaria infections and huge levels of antibody in their veins. The researchers tried an experiment: They formulated a preparation that absorbed the malaria antibodies, treated the blood samples with it, then retested them. Eighty percent of the suspected HIV infections vanished.
The researchers themselves admitted that these findings were inconclusive. Still, considering that Africa is home to an estimated ninety percent of the world's malaria cases, the implications of the report seemed intriguing. I asked Dr. Luc Noel, the WHO's blood-transfusion-safety chief, for his opinion. He insisted there was no cause for concern. Then he handed me a booklet detailing the outcome of the WHO's evaluation of commercial ELISA assays. In it, I found two of the three tests that had been used in South America - the very ones that supposedly went haywire, kits manufactured in Britain and France, respectively. One was rated By WHO as ninety-seven percent accurate, the other, ninety-eight percent.
On the other hand, I couldn't help noticing that according to the literature Noel had given me, the disease police apply at least five confirmatory tests to every blood sample before such high accuracy rates are achieved. What happens if you use just two, or one? And if your subjects are Africans whose immune systems are often, as UNAIDS head Peter Piot once phrased it, "in a chronically activated state associated with chronic viral and parasitic exposure." There may be an answer of sorts.
The Uganda Virus Research Institute is possibly Africa's greatest citadel of HIV studies. Seated on a hilltop overlooking Lake Victoria and generously funded by the British government, the UVRI employs around 200 scientists and support personnel, runs an array of advanced AIDS studies, tests experimental drugs, labors to produce an AIDS vaccine and has generated scores of scientific papers during the past decade.
In 1999, the Institute screened thousands of blood samples using ELISA tests that has achieved excellent results in a WHO evaluation. Test-driven in a lab in Antwerp, Belgium, one test scored 99.1 percent accuracy, while the other achieved a perfect 100. But in the field, in Africa, it was another story entirely. There, exactly 3,369 samples came up positive on one ELISA, but only 2,237 of those (66 percent) remained positive after confirmatory testing. In other words: a third of Ugandans who tested positive on at least one of these supposedly near-perfect ELISAs were not carrying the virus. What does this say about countries where AIDS statistics are based on a single ELISA? A high-ranking source at UVRI - one who insisted on anonymity - said that the WHO estimates for AIDS in such countries "could be as much as one-third higher than they actually are."
I took this up with Dr. Neff Walker, a senior adviser at UNAIDS, who at first seemed puzzled. "The standard WHO/UNAIDS protocol calls for two tests in countries with a higher prevalence," he said.
But according to a WHO report, "Confirmation by a second test is necessary only in settings where estimated HIV prevalence is known to be less than ten percent." This means that in countries like mine, estimates are based on one unconfirmed test.
Dr. Walker conceded that, but said it wasn't particularly important given that most African counties have what he called "quality assurance" programs in place.
"I feel," he said, "that if a government found any evidence of too many false positives in their testing, they would report it. Governments would like to find evidence of a lower prevalence, as would we all, and since they have the data to easily check your hypothesis, they would do so and report it."
But would they? High AIDS numbers are not entirely undesirable in poverty-stricken African countries. High numbers mean deepening crisis, and crisis typically generates cash. The results are now manifest: planeloads of safari scientists flying in to oversee research projects or cutting-edge interventions, and bringing with them huge inflows of foreign currency - about $1 billion a year in AIDS-related funding, and most of it destined for the countries with the highest numbers of infected citizens.
On the ground, these dollars translate into patronage for politicians and good jobs for their struggling constituents. In Uganda, an AIDS councelor earns twenty times more than a schoolteacher. In Tanzania. AIDS doctors can increase their income just by saving the hard-currency per diums they earn while attending international conferences. Here in South Africa, entrepreneurs are piling into the AIDS business at an astonishing rate, setting up consultancies, selling herbal immune boosters and vitamin supplements, devising new insurance products, distributing condoms, staging benefits, forming theater troupes that take the AIDS prevention message into schools. A friend of mine is co-producing a slew of TV documentaries about AIDS, all for foreign markets. Another friend has got his fingers crossed, since his agency is on the shortlist to land a $6 million safe-sex ad campaign.
Sometimes it seemed I was the only one in South Africa who found this odd. Dr. Ed Rybicki, a University of Cape Town microbiologist, caught sight of part of this article while it was being prepared and found it alarming. "Vast inflation of HIV figures by bad tests?" he wrote in an email. "Naaaaah. The test manufacturers have done a hell of a lot of research, which is not published because it is part of quality control, rather than part of a global cartel conspiracy to make Africans HIV-positive!" He allowed that there was "probably some truth" in stories about "various factors confusing the HIV test" but accused me of stringing them together in an irresponsible way. "Crap!" he ultimately declared. "Utter garbage."
I defer to Dr. Rybicki in matters of science, but his denunciation rested on the flawed assumption that, as he wrote to me, "In South Africa, tests are repeated, and repeat positives are confirmed by another method, meaning there is a threefold redundancy." Maybe that's how it works in universities or research labs. But when it comes to UNAIDS statistics, one test is evidently enough.
Can You Wait Ten Years?
And so we return to where we started, standing over a coffin under a bleak Soweto sky, making a clumsy speech about a sad and premature death. Adelaide Ntsele died of AIDS, but the word didn't appear on her death certificate. Here in Africa, those little letters stigmatize, so doctors usually put down something gentler to spare the family further pain. In Adelaide's case, they wrote TB. But her sister Elizabeth had no such need of such false consolation. She donned a red-ribbon baseball cap and appeared on national TV, telling the truth: "My sister had HIV/AIDS." As a nurse, Elizabeth had no qualms with the doctors' diagnosis, and she concurred with their decision to forgo surgery and let Adelaide die. "It was God's will," she says, and she was at peace with it. I was the one beset by all the doubts.
Did Adelaide really die of AIDS? It certainly looked that way, but she also had TB, the second-most-frightening disease in the world today, on the rise everywhere, even in rich countries, sometimes in a virulent drug-resistant form that kills half its victims, according to the CIA's recent report on infectious disease. Eight years ago, the WHO declared resurgent TB a "global emergency," but the contagion continues to spread, particularly in the cluster of southern African countries simultaneously stricken by the worst TB and HIV epidemics on the planet. It takes a blood test to establish the underlying presence of an HIV infection in people with TB, and at least one scientist who knows about these things has imputed that the tests might not be entirely reliable.
Back in 1994, Max Essex, head of the Harvard AIDS Institute, and some collegues of his observed a "very high" (sixty-three percent) rate of ELISA false positives among lepers in central Africa. Mystified, they probed deeper and pinpointed the cause: two cross-reacting antigens, one of which, lipoarabinomannan, or LAM, also occurs in the organism that causes TB. This prompted Essex and his collaborators to warn that ELISA results should be "interpreted with caution" in areas where HIV and TB were co-endemic. Indeed, they speculated that existing antibody tests "may not be sufficient for HIV diagnosis" in settings where TB and related diseases are commonplace.
Essex was not alone in warning us that antibody tests can be confused by diseases and conditions having nothing to do with HIV and AIDS. An article in the Journal of the American Medical Association in 1996 said that "false-positive results can be caused by nonspecific reactions in persons with immunologic disturbances (e.g., systemic lupus erythematosus or rheumatiod arthritis), multiple transfusions or recent influenza or rabies vaccination.... To prevent the serious consequensces of a false-positive diagnosis of HIV infection, confirmation of positive ELISA results is necessary.... In practice, false-positive diagnoses can result form contaminated or mislabeled specimens, cross-reacting antibodies, failure to perform confirmatory tests.... or misunderstanding of reported results by clinicians or patients." These are not the only factors that can cause false positives. How about pregnancy? The U.S. National Institutes of Health states that multiple pregnancy can confuse HIV tests. In the past few years, similar claims have been made for measles, dengue fever, Ebola, Marburg and malaria (again).
But let's put all that science aside, for a moment. Lots of people thoght it was wrong for me even to pose questions such as these, especially at a moment when rich countries, rich corporations and rich men were considering billion-dollar contributions to a Global AIDS Superfund. They were brought to this point by a ceaseless barrage of stories and images of unbearable suffering in Africa, all buttressed by Geneva's death projections. Casting doubt on those estimates was tantamount to murder, or so said Dr, Rybicki, the Cape Town microbiologist.
"AIDS is real, and is killing Africans in very large numbers," he wrote. "Presenting arguments that purport to show otherwise in the popular press is simply going to compound the damage already done by Mbeki. And a lot more people may die who may not have otherwise."
Rybicki was right. But what are the facts? After a year of looking, I still can't say for sure.
When I embarked on this story, you may recall, no massive rise in registered deaths was discernable in South Africa. A year later, I decided to return to my point of departure to see if the discrepancy persisted. I wrote to the country's Department of Home Affairs,which manages the death register, and asked for the latest numbers. In response came a set of figures somewhat different from those initially provided - the consequence, I am told of people who died without any identity documents. Here is the final analysis:
Deaths registered in 1996 - 363,238.
Deaths registered in 2000 - 457,335.
As you see, registered deaths have indeed risen - not to the extent prophesied by the United Nations, perhaps, but there is definite movement in an ominous direction. Deaths are up across the board, but concentrated in certain critical age groups: females in their twenties, and males age thirty to thirty-nine.
A team of experts commissioned by the Medical Research Council has studied this changing death pattern and found it to be "largely consistent with the pattern predicted by [ours] and other models of the AIDS epidemic." Their conclusion: AIDS has become the "biggest cause" of mortality in South Africa, responsible for forty percent of adult deaths.
And yet, and yet, and yet, even this is no the end of our tale, because another governmental body, Stats SA, has challenged these findings. The Washington Post reported that the South African census bureau called the MRC study "badly flawed," saying "the samples were not representative, and assumptions about the probability of the transmission of the virus that causes AIDS were not necessarily accurate."
And that's my story: enigma upon enigma, riddle leading to riddle, and no reprieve from doubt. Local actuarial models say 352,000 South Africans have died from AIDS since the epidemic began. The MRC says 517,000. The figure from a group I haven't even mentioned yet, the United Nations Population Division, is double that - 1.06 million - and the unofficial WHO/UNAIDS projections are even higher. I have wasted a year of my time and thousands of Rolling Stone's editorial-budget dollars, and all I can really tell you is that my faith in science has been dented. These guys can't agree on anything.
Ordinary Africans everywhere see that the scourge is moving among them. The guide who showed me around Uganda had lost two siblings. Our driver had lost three. On the banks of the Kagera River, where the plague began, we met a sad old man who said all five of his children had died of it.
But ask these people about access to health care, and they laugh ruefully. "The coffee price is collapsing," they say. No one has money. We can't even afford transport to hospital, let alone medicine." All across rural east Africa, doctors confirmed the charge: no money, no medicine. Even mission hospitals now ask patients for money.
"What can we do?" asks Father Boniface Kaayabula, who works at a Catholic mission in rural Uganda. "We have no money, too. We must ask people to pay, and only a very few can."
So what do poor Africans do if they fall sick? They go to roadside shacks called "drug stores" and buy snake oil. Chloroquine for malaria, on a continent where that former miracle drug has lost most of its curative power; nameless black-market antibiotics for lung diseases, in a setting where up to sixty percent of pneumonia is drug-resistant; penicillin for gonorrhea, administered by an amateur "injectionist" who might be unaware that the quantity needed to knock out the infection has risen a hundredfold in the past decade. For the poorest of the poor, even such dubious nostrums are beyond reach. They try to cure themselves with herbs, they fail, and they die.
What's to be done? Dr. Joseph Sonnabend is a South Africa-born physician who was running a venereal-disease clinic in New York back in the early Eighties, when GRID first appeared. He became known throughout the world as a pioneer in AIDS treatment. When President Mbeki launched his controversial inquiry into the disease last year, Sonnabend came home to participate, an experience he likens to "entering hell."
As founder of the AIDS Medical Foundation, which became the American AIDSResearch Foundation, or AmFAR, Sonnabend has no patience with thosedissidents who dispute the syndrome's existance or HIV's power to cause it.But he also believes there are "opportunists" and "phonies" whose chiefskill is "manipulation of fear for advancement in terms of money andpower." In fact, he quit AmFAR, his own group, because he felt it wasexaggerating the threat of a heterosexual epidemic. A decade later, he'sstill fighting the lonely battle for wise policies, especially inAfrica.
In Pretoria, he says, one faction argued for the bulk of available funds tobe committed to the purchase of AIDS drugs. But merely dumping AIDS drugsinto resource-poor countries is pointless, Sonnabend argued, although hedoes believe there are limited situations where they could be safely andeffectively used. The prevention of mother-to-child transmission is one;another is in people with advanced disease where facilities to adequatelymonitor the use of drugs are in place. Unfortunatly, the cost ofestablishing an infrastructure to do this on a large scale would beenormous, and without this hardly anyone would benefit, save drugmanufacturers.
The answer, he feels, is to eliminate conditions that render Africansvulnerable to HIV in the first place. A year down the line, Sonnabend isstill trying to organize an international conference to discuss thedisposition of the money lodged in the Global AIDS Superfund. The way hesees it, $1 billion a year would be enough to transform the lives ofordinary Africans and curb the AIDS epidemic, but only if it's notsquandered on unsustainable "drugs into people" programs.
"There's a place for AIDS drugs and prevention campaigns," he says, "butit's not the only answer. We need to roll out clean water and propersanitation. Do something about nutrition. Put in some basic healthinfrastructure. Develop effective drugs for malaria and TB and get them toeveryone who needs them."
On the other hand, we have researchers like the ones from HarvardUniversity who insist that biomedical intervetion is morally inescapeable."We can raise people from their deathbeds," said professor Bruce Walker.They calculated that it should be possible to provide Africans with AIDSdrugs for as little as $1,100 a year.
Granted, says Sonnabend, but this makes little sense if that one luckyperson's neighbors are dying for lack of medicines that cost a fewcents.
So who's right? Depends on the numbers, I guess. In the end, I attempted tobring all my unanswered questions on that topic to the man who was therewhen the epidemic first hit this continent, Dr. Peter Piot, who has todayrisen to the role of chief of UNAIDS.
But my call to him was directed instead to UNAIDS' chief epidemiologist, aphysician named Dr. Bernhard Schwartlander.
The UNAIDS computer model of Africa's epidemic is in fact completelydependable, Dr. Schwartlander says because it relies on a "very simpleformula. You take the median survival time - around nine years in Africa.You say this is roughly the distribution curve. Calculation of deaths iscompletly plausable if - and this is important - you have a good idea ofthe prevalence of HIV and how it spreads over time."
Why then, I asked, do we have so many different estimates of AIDS deaths inSouth Africa?
"I'm not shocked," he said. "The models may completely disagree at aparticular point in time, but in the end the curves look incrediblysimilar. They're goddamn consistant."
If that's true, I said, then why would we have 457,000 registered deathshere last year when the UN says 400,000 of them died of AIDS? One of thosenumbers must be wrong.
"You say there are 457,000 registered deaths in South Africa?"Schwartlander said, momentarily nonplussed. "This is an estimate based onprojections."
No, said I, it's the actual number of registered deaths last year.
"We don't really know," he replied. "Things are moving very fast. What isthe total number of people who actually die? For all we know, it could bemuch higher. HIV has never existed in mankind before, and there's no anchorpoint set in stone." The UNAIDS numbers are, after all, only estimates. Weare not saying this is the number. We are saying this is our bestestimate.Ten years from now, we won't have these problems. Ten years fromnow, we'll know everything."
Ten years! Had I known, I could have saved myself a lot of grief. For evenas I tried to track down the old numbers, bigger new ones were supplantingthem - 17 million Africans dead of AIDS and 25 million more with HIV,UNAIDS now estimates; not one in five South African adults infected but onein four. Are these numbers right? Who knows. Feel free to publish this,Jann, but if it drives you as mad as it has driven me, I'llunderstand.
Rian Malan is the author of "My Traitor's Heart: A South African Exile Returns to Face His Country, His Tribe and His Conscience."
Over the years I’ve seen a lot of charts co-relating AIDS incidence with everything from language to circumcision rates.
Roth also notes that Islamic areas tend to have lower rates. This may well be true (among other things, the widespread Muslim custom of washing before and after sex may help). On the other hand, they may have lower reporting rates, for reason of stigma. (This may be true of the Catholic Christian areas, too.)
Why AIDS has spread so extensively in Africa, and why rates are so different in different parts of Africa, remains a mystery. Religion might be the explanation, but there are a lot of other candidates.
The incidence…is more likely to be related to famine than to religion. The highest rates are in those countries whose populations are starving….None of the Muslim countries make the list. Famine is always followed by pestilence. The body can’t fend off infection when it’s emaciated, even when given drugs to help. That’s why the solution to AIDS and other diseases in places like Africa is not likely to be found in just throwing money and drugs at them.
Ted Esler provided a link to the Mission Review website, which gives access to a huge amount of material detailing the many positive initiatives being undertaken by mission organisations to combat the global HIV/AIDS epidemic.
And Nathan M. wrote:
In presenting the Gospel anywhere in the world, we have to figure out how to better present the “go and sin no more” aspects of it. There needs to be grace, but there needs to be change as well. Those looking for a high count of those saved will emphasize the first. Those looking to control…will try and force the second…. Christianity can and must hold both in balance. We needn’t wait to get our house perfectly in order before spreading the Gospel (we won't be there until we reach Heaven), but that doesn't excuse our own lack of seriousness towards God's demands.
I should say that my article was to some degree intended to be thought-provoking. I was always dubious about the accuracy of HIV/AIDS reporting.
I also wonder about the claims that certain African countries are highly Christian. The Operation World handbook does an excellent job in standardising and presenting global statistics from a myriad of sources. But many of these statistics are, to put it mildly, of dubious reliability, for a variety of reasons.
Take my own country Australia. It is said to be 67.5% Christian (based on census data), despite being a hugely secular and materialistic place, with a strong anti-Christian strain prominent in the media and throughout some other institutions. Church attendance is low, and I’d hardly call us a Christian country at all.
But let’s end on a note of optimism. The African country with the largest number of evangelical Christians is Uganda. According to Operation World, more than 40% of the population are evangelical Christians, one of the highest rates in the world. Uganda also has a low (for Africa) adult HIV/AIDS rate of just 5%.
According to Operation World:
Uganda is the first country in the world with a massive AIDS problem to…reduce the numbers of the afflicted, from possibly 25% in 1992…. Both government and churches faced up to the terrible calamity and have successfully worked to achieve this reduction.
Praise the Lord.