Death Stalks A Continent

By Johanna McGeary

Imagine your life this way.

You get up in the morning and breakfast with your three kids. One is already doomed to die in infancy. Your husband works 200 miles away, comes home twice a year and sleeps around in between. You risk your life in every act of sexual intercourse. You go to work past a house where a teenager lives alone tending young siblings without any source of income. At another house, the wife was branded a whore when she asked her husband to use a condom, beaten silly and thrown into the streets. Over there lies a man desperately sick without access to a doctor or clinic or medicine or food or blankets or even a kind word. At work you eat with colleagues, and every third one is already fatally ill. You whisper about a friend who admitted she had the plague and whose neighbors stoned her to death. Your leisure is occupied by the funerals you attend every Saturday. You go to bed fearing adults your age will not live into their 40s. You and your neighbors and your political and popular leaders act as if nothing is happening.

Across the southern quadrant of Africa, this nightmare is real. The word not spoken is AIDS, and here at ground zero of humanity's deadliest cataclysm, the ultimate tragedy is that so many people don't know--or don't want to know--what is happening.

As the HIV virus sweeps mercilessly through these lands--the fiercest trial Africa has yet endured--a few try to address the terrible depredation. The rest of society looks away. Flesh and muscle melt from the bones of the sick in packed hospital wards and lonely bush kraals. Corpses stack up in morgues until those on top crush the identity from the faces underneath. Raw earth mounds scar the landscape, grave after grave without name or number. Bereft children grieve for parents lost in their prime, for siblings scattered to the winds.

The victims don't cry out. Doctors and obituaries do not give the killer its name. Families recoil in shame. Leaders shirk responsibility. The stubborn silence heralds victory for the disease: denial cannot keep the virus at bay.

The developed world is largely silent too. AIDS in Africa has never commanded the full-bore response the West has brought to other, sometimes lesser, travails. We pay sporadic attention, turning on the spotlight when an international conference occurs, then turning it off. Good-hearted donors donate; governments acknowledge that more needs to be done. But think how different the effort would be if what is happening here were happening in the West.

By now you've seen pictures of the sick, the dead, the orphans. You've heard appalling numbers: the number of new infections, the number of the dead, the number who are sick without care, the number walking around already fated to die.

But to comprehend the full horror AIDS has visited on Africa, listen to the woman we have dubbed Laetitia Hambahlane in Durban or the boy Tsepho Phale in Francistown or the woman who calls herself Thandiwe in Bulawayo or Louis Chikoka, a long-distance trucker. You begin to understand how AIDS has struck Africa--with a biblical virulence that will claim tens of millions of lives--when you hear about shame and stigma and ignorance and poverty and sexual violence and migrant labor and promiscuity and political paralysis and the terrible silence that surrounds all this dying. It is a measure of the silence that some asked us not to print their real names to protect their privacy.

Theirs is a story about what happens when a disease leaps the confines of medicine to invade the body politic, infecting not just individuals but an entire society. As AIDS migrated to man in Africa, it mutated into a complex plague with confounding social, economic and political mechanics that locked together to accelerate the virus' progress. The region's social dynamics colluded to spread the disease and help block effective intervention.

We have come to three countries abutting one another at the bottom of Africa--Botswana, South Africa, Zimbabwe--the heart of the heart of the epidemic. For nearly a decade, these nations suffered a hidden invasion of infection that concealed the dimension of the coming calamity. Now the omnipresent dying reveals the shocking scale of the devastation.

AIDS in Africa bears little resemblance to the American epidemic, limited to specific high-risk groups and brought under control through intensive education, vigorous political action and expensive drug therapy. Here the disease has bred a Darwinian perversion. Society's fittest, not its frailest, are the ones who die--adults spirited away, leaving the old and the children behind. You cannot define risk groups: everyone who is sexually active is at risk. Babies too, unwittingly infected by mothers. Barely a single family remains untouched. Most do not know how or when they caught the virus, many never know they have it, many who do know don't tell anyone as they lie dying. Africa can provide no treatment for those with AIDS.

They will all die, of tuberculosis, pneumonia, meningitis, diarrhea, whatever overcomes their ruined immune systems first. And the statistics, grim as they are, may be too low. There is no broad-scale AIDS testing: infection rates are calculated mainly from the presence of HIV in pregnant women. Death certificates in these countries do not record AIDS as the cause. "Whatever stats we have are not reliable," warns Mary Crewe of the University of Pretoria's Center for the Study of AIDS. "Everybody's guessing."

THE TB PATIENT

Case no. 309 in the Tugela Ferry home-care program shivers violently on the wooden planks someone has knocked into a bed, a frayed blanket pulled right up to his nose. He has the flushed skin, overbright eyes and careful breathing of the tubercular. He is alone, and it is chilly within the crumbling mud walls of his hut at Msinga Top, a windswept outcrop high above the Tugela River in South Africa's KwaZulu-Natal province. The spectacular view of hills and veld would gladden a well man, but the 22-year-old we will call Fundisi Khumalo, though he does not know it, has AIDS, and his eyes seem to focus inward on his simple fear.

Before he can speak, his throat clutches in gasping spasms. Sharp pains rack his chest; his breath comes in shallow gasps. The vomiting is better today. But constipation has doubled up his knees, and he is too weak to go outside to relieve himself. He can't remember when he last ate. He can't remember how long he's been sick--"a long time, maybe since six months ago." Khumalo knows he has TB, and he believes it is just TB. "I am only thinking of that," he answers when we ask why he is so ill.

But the fear never leaves his eyes. He worked in a hair salon in Johannesburg, lived in a men's hostel in one of the cheap townships, had "a few" girlfriends. He knew other young men in the hostel who were on-and-off sick. When they fell too ill to work anymore, like him, they straggled home to rural villages like Msinga Top. But where Khumalo would not go is the hospital. "Why?" he says. "You are sick there, you die there."

"He's right, you know," says Dr. Tony Moll, who has driven us up the dirt track from the 350-bed hospital he heads in Tugela Ferry. "We have no medicines for AIDS. So many hospitals tell them, 'You've got AIDS. We can't help you. Go home and die.'" No one wants to be tested either, he adds, unless treatment is available. "If the choice is to know and get nothing," he says, "they don't want to know."

Here and in scattered homesteads all over rural Africa, the dying people say the sickness afflicting their families and neighbors is just the familiar consequence of their eternal poverty. Or it is the work of witchcraft. You have done something bad and have been bewitched. Your neighbor's jealousy has invaded you. You have not appeased the spirits of your ancestors, and they have cursed you. Some in South Africa believe the disease was introduced by the white population as a way to control black Africans after the end of apartheid.

Ignorance about AIDS remains profound. But because of the funerals, southern Africans can't help seeing that something more systematic and sinister lurks out there. Every Saturday and often Sundays too, neighbors trudge to the cemeteries for costly burial rites for the young and the middle-aged who are suddenly dying so much faster than the old. Families say it was pneumonia, TB, malaria that killed their son, their wife, their baby. "But you starting to hear the truth," says Durban home-care volunteer Busi Magwazi. "In the church, in the graveyard, they saying, 'Yes, she died of AIDS.' Oh, people talking about it even if the families don't admit it."

Ignorance is the crucial reason the epidemic has run out of control. Surveys say many Africans here are becoming aware there is a sexually transmitted disease called AIDS that is incurable. But they don't think the risk applies to them. And their vague knowledge does not translate into changes in their sexual behavior. It's easy to see why so many don't yet sense the danger when few talk openly about the disease. And Africans are beset by so plentiful a roster of perils--famine, war, the violence of desperation or ethnic hatred, the regular illnesses of poverty, the dangers inside mines or on the roads--that the delayed risk of AIDS ranks low.

THE OUTCAST

To acknowledge AIDS in yourself is to be branded as monstrous. Laetitia Hambahlane (not her real name) is 51 and sick with AIDS. So is her brother. She admits it; he doesn't. In her mother's broken-down house in the mean streets of Umlazi township, though, Laetitia's mother hovers over her son, nursing him, protecting him, resolutely denying he has anything but TB, though his sister claims the sure symptoms of AIDS mark him. Laetitia is the outcast, first from her family, then from her society.

For years Laetitia worked as a domestic servant in Durban and dutifully sent all her wages home to her mother. She fell in love a number of times and bore four children. "I loved that last man," she recalls. "After he left, I had no one, no sex." That was 1992, but Laetitia already had HIV.

She fell sick in 1996, and her employers sent her to a private doctor who couldn't diagnose an illness. He tested her blood and found she was HIV positive. "I wish I'd died right then," she says, as tears spill down her sunken cheeks. "I asked the doctor, 'Have you got medicine?' He said no. I said, 'Can't you keep me alive?'" The doctor could do nothing and sent her away. "I couldn't face the word," she says. "I couldn't sleep at night. I sat on my bed, thinking, praying. I did not see anyone day or night. I ask God, Why?"

Laetitia's employers fired her without asking her exact diagnosis. For weeks she could not muster the courage to tell anyone. Then she told her children, and they were ashamed and frightened. Then, harder still, she told her mother. Her mother raged about the loss of money if Laetitia could not work again. She was so angry she ordered Laetitia out of the house. When her daughter wouldn't leave, the mother threatened to sell the house to get rid of her daughter. Then she walled off her daughter's room with plywood partitions, leaving the daughter a pariah, alone in a cramped, dark space without windows and only a flimsy door opening into the alley. Laetitia must earn the pennies to feed herself and her children by peddling beer, cigarettes and candy from a shopping cart in her room, when people are brave enough to stop by her door. "Sometimes they buy, sometimes not," she says. "That is how I'm surviving."

Her mother will not talk to her. "If you are not even accepted by your own family," says Magwazi, the volunteer home-care giver from Durban's Sinoziso project who visits Laetitia, "then others will not accept you." When Laetitia ventures outdoors, neighbors snub her, tough boys snatch her purse, children taunt her. Her own kids are tired of the sickness and don't like to help her anymore. "When I can't get up, they don't bring me food," she laments. One day local youths barged into her room, cursed her as a witch and a whore and beat her. When she told the police, the youths returned, threatening to burn down the house.

But it is her mother's rejection that wounds Laetitia most. "She is hiding it about my brother," she cries. "Why will she do nothing for me?" Her hands pick restlessly at the quilt covering her paper-thin frame. "I know my mother will not bury me properly. I know she will not take care of my kids when I am gone."

Jabulani Syabusi would use his real name, but he needs to protect his brother. He teaches school in a red, dusty district of KwaZulu-Natal. People here know the disease is all around them, but no one speaks of it. He eyes the scattered huts that make up his little settlement on an arid bluff. "We can count 20 who died just here as far as we can see. I personally don't remember any family that told it was AIDS," he says. "They hide it if they do know."

Syabusi's own family is no different. His younger brother is also a teacher who has just come home from Durban too sick to work anymore. He says he has tuberculosis, but after six months the tablets he is taking have done nothing to cure him. Syabusi's wife Nomsange, a nurse, is concerned that her 36-year-old brother-in-law may have something worse. Syabusi finally asked the doctor tending his brother what is wrong. The doctor said the information is confidential and will not tell him. Neither will his brother. "My brother is not brave enough to tell me," says Syabusi, as he stares sadly toward the house next door, where his only sibling lies ill. "And I am not brave enough to ask him."

Kennedy Fugewane, a cheerful, elderly volunteer counselor, sits in an empty U.S.-funded clinic that offers fast, pinprick blood tests in Francistown, Botswana, pondering how to break through the silence. This city suffers one of the world's highest infection rates, but people deny the disease because HIV is linked with sex. "We don't reveal anything," he says. "But people are so stigmatized even if they walk in the door." Africans feel they must keep private anything to do with sex. "If a man comes here, people will say he is running around," says Fugewane, though he acknowledges that men never do come. "If a woman comes, people will say she is loose. If anyone says they got HIV, they will be despised."

Pretoria University's Mary Crewe says, "It is presumed if you get AIDS, you have done something wrong." HIV labels you as living an immoral life. Embarrassment about sexuality looms more important than future health risks. "We have no language to talk candidly about sex," she says, "so we have no civil language to talk about AIDS." Volunteers like Fugewane try to reach out with flyers, workshops, youth meetings and free condoms, but they are frustrated by a culture that values its dignity over saving lives. "People here don't have the courage to come forward and say, 'Let me know my HIV status,'" he sighs, much less the courage to do something about it. "Maybe one day..."

Doctors bow to social pressure and legal strictures not to record AIDS on death certificates. "I write TB or meningitis or diarrhea but never AIDS," says South Africa's Dr. Moll. "It's a public document, and families would hate it if anyone knew." Several years ago, doctors were barred even from recording compromised immunity or HIV status on a medical file; now they can record the results of blood tests for AIDS on patient charts to protect other health workers. Doctors like Moll have long agitated to apply the same openness to death certificates.

THE TRUCK DRIVER

Here, men have to migrate to work, inside their countries or across borders. All that mobility sows HIV far and wide, as Louis Chikoka is the first to recognize. He regularly drives the highway that is Botswana's economic lifeline and its curse. The road runs for 350 miles through desolate bush that is the Texas-size country's sole strip of habitable land, home to a large majority of its 1.5 million people. It once brought prospectors to Botswana's rich diamond reefs. Now it's the link for transcontinental truckers like Chikoka who haul goods from South Africa to markets in the continent's center. And now the road brings AIDS.

Chikoka brakes his dusty, diesel-belching Kabwe Transport 18-wheeler to a stop at the dark roadside rest on the edge of Francistown, where the international trade routes converge and at least 43% of adults are HIV-positive. He is a cheerful man even after 12 hard hours behind the wheel freighting rice from Durban. He's been on the road for two weeks and will reach his destination in Congo next Thursday. At 39, he is married, the father of three and a long-haul trucker for 12 years. He's used to it.

Lighting up a cigarette, the jaunty driver is unusually loquacious about sex as he eyes the dim figures circling the rest stop. Chikoka has parked here for a quickie. See that one over there, he points with his cigarette. "Those local ones we call bitches. They always waiting here for short service." Short service? "It's according to how long it takes you to ejaculate," he explains. "We go to the 'bush bedroom' over there [waving at a clump of trees 100 yds. away] or sometimes in the truck. Short service, that costs you 20 rands [$2.84]. They know we drivers always got money."

Chikoka nods his head toward another woman sitting beside a stack of cardboard cartons. "We like better to go to them," he says. They are the "businesswomen," smugglers with gray-market cases of fruit and toilet paper and toys that they need to transport somewhere up the road. "They come to us, and we negotiate privately about carrying their goods." It's a no-cash deal, he says. "They pay their bodies to us." Chikoka shrugs at a suggestion that the practice may be unhealthy. "I been away two weeks, madam. I'm human. I'm a man. I have to have sex."

What he likes best is dry sex. In parts of sub-Saharan Africa, to please men, women sit in basins of bleach or saltwater or stuff astringent herbs, tobacco or fertilizer inside their vagina. The tissue of the lining swells up and natural lubricants dry out. The resulting dry sex is painful and dangerous for women. The drying agents suppress natural bacteria, and friction easily lacerates the tender walls of the vagina. Dry sex increases the risk of HIV infection for women, already two times as likely as men to contract the virus from a single encounter. The women, adds Chikoka, can charge more for dry sex, 50 or 60 rands ($6.46 to $7.75), enough to pay a child's school fees or to eat for a week.

Chikoka knows his predilection for commercial sex spreads AIDS; he knows his promiscuity could carry the disease home to his wife; he knows people die if they get it. "Yes, HIV is terrible, madam," he says as he crooks a finger toward the businesswoman whose favors he will enjoy that night. "But, madam, sex is natural. Sex is not like beer or smoking. You can stop them. But unless you castrate the men, you can't stop sex--and then we all die anyway."

Millions of men share Chikoka's sexually active lifestyle, fostered by the region's dependence on migrant labor. Men desperate to earn a few dollars leave their women at hardscrabble rural homesteads to go where the work is: the mines, the cities, the road. They're housed together in isolated males-only hostels but have easy access to prostitutes or a "town wife" with whom they soon pick up a second family and an ordinary STD and HIV. Then they go home to wives and girlfriends a few times a year, carrying the virus they do not know they have. The pattern is so dominant that rates of infection in many rural areas across the southern cone match urban numbers.

If HIV zeros in disproportionately on poor migrants, it does not skip over the educated or the well paid. Soldiers, doctors, policemen, teachers, district administrators are also routinely separated from families by a civil-service system that sends them alone to remote rural posts, where they have money and women have no men. A regular paycheck procures more access to extramarital sex. Result: the vital professions are being devastated.

Schoolmaster Syabusi is afraid there will soon be no more teachers in his rural zone. He has just come home from a memorial for six colleagues who died over the past few months, though no one spoke the word AIDS at the service. "The rate here--they're so many," he says, shaking his head. "They keep on passing it at school." Teachers in southern Africa have one of the highest group infection rates, but they hide their status until the telltale symptoms find them out.

Before then, the men--teachers are mostly men here--can take their pick of sexual partners. Plenty of women in bush villages need extra cash, often to pay school fees, and female students know they can profit from a teacher's favor. So the schoolmasters buy a bit of sex with lonely wives and trade a bit of sex with willing pupils for A's. Some students consider it an honor to sleep with the teacher, a badge of superiority. The girls brag about it to their peers, preening in their ability to snag an older man. "The teachers are the worst," says Jabulani Siwela, an AIDS worker in Zimbabwe who saw frequent teacher-student sex in his Bulawayo high school. They see a girl they like; they ask her to stay after class; they have a nice time. "It's dead easy," he says. "These are men who know better, but they still do it all the time."

THE PROSTITUTE

The workingwoman we meet directs our car to a reedy field fringing the gritty eastern townships of Bulawayo, Zimbabwe. She doesn't want neighbors to see her being interviewed. She is afraid her family will find out she is a prostitute, so we will call her Thandiwe. She looked quite prim and proper in her green calf-length dress as she waited for johns outside 109 Tongogaro Street in the center of downtown. So, for that matter, do the dozens of other women cruising the city's dim street corners: not a mini or bustier or bared navel in sight. Zimbabwe is in many ways a prim and proper society that frowns on commercial sex work and the public display of too much skin.

That doesn't stop Thandiwe from earning a better living turning tricks than she ever could doing honest work. Desperate for a job, she slipped illegally into South Africa in 1992. She cleaned floors in a Johannesburg restaurant, where she met a cook from back home who was also illegal. They had two daughters, and they got married; he was gunned down one night at work.

She brought his body home for burial and was sent to her in-laws to be "cleansed." This common practice gives a dead husband's brother the right, even the duty, to sleep with the widow. Thandiwe tested negative for HIV in 1998, but if she were positive, the ritual cleansing would have served only to pass on the disease. Then her in-laws wanted to keep her two daughters because their own children had died, and marry her off to an old uncle who lived far out in the bush. She fled.

Alone, Thandiwe grew desperate. "I couldn't let my babies starve." One day she met a friend from school. "She told me she was a sex worker. She said, 'Why you suffer? Let's go to a place where we can get quick bucks.'" Thandiwe hangs her head. "I went. I was afraid. But now I go every night."

She goes to Tongogaro Street, where the rich clients are, tucking a few condoms in her handbag every evening as the sun sets and returning home strictly by 10 so that she won't have to service a taxi-van driver to get a ride back. Thandiwe tells her family she works an evening shift, just not at what. "I get 200 zim [$5] for sex," she says, more for special services. She uses two condoms per client, sometimes three. "If they say no, I say no." But then sometimes resentful johns hit her. It's pay-and-go until she has pocketed 1,000 or 1,500 Zimbabwe dollars and can go home--with more cash than her impoverished neighbors ever see in their roughneck shantytown, flush enough to buy a TV and fleece jammies for her girls and meat for their supper.

"I am ashamed," she murmurs. She has stopped going to church. "Every day I ask myself, 'When will I stop this business?' The answer is, 'If I could get a job'..." Her voice trails off hopelessly. "At the present moment, I have no option, no other option." As trucker Chikoka bluntly puts it, "They give sex to eat. They got no man; they got no work; but they got kids, and they got to eat." Two of Thandiwe's friends in the sex trade are dying of AIDS, but what can she do? "I just hope I won't get it."

In fact, casual sex of every kind is commonplace here. Prostitutes are just the ones who admit they do it for cash. Everywhere there's premarital sex, sex as recreation. Obligatory sex and its abusive counterpart, coercive sex. Transactional sex: sex as a gift, sugar-daddy sex. Extramarital sex, second families, multiple partners. The nature of AIDS is to feast on promiscuity.

Rare is the man who even knows his HIV status: males widely refuse testing even when they fall ill. And many men who suspect they are HIV positive embrace a flawed logic: if I'm already infected, I can sleep around because I can't get it again. But women are the ones who progress to full-blown AIDS first and die fastest, and the underlying cause is not just sex but power. Wives and girlfriends and even prostitutes in this part of the world can't easily say no to sex on a man's terms. It matters little what comes into play, whether it is culture or tradition or the pathology of violence or issues of male identity or the subservient status of women.

Beneath a translucent scalp, the plates of Gertrude Dhlamini's cranium etch a geography of pain. Her illness is obvious in the thin, stretched skin under which veins throb with the shingles that have blinded her left eye and scarred that side of her face. At 39, she looks 70. The agonizing thrush, a kind of fungus, that paralyzed her throat has ebbed enough to enable her to swallow a spoon or two of warm gruel, but most of the nourishment flows away in constant diarrhea. She struggles to keep her hand from scratching restlessly at the scaly rash flushing her other cheek. She is not ashamed to proclaim her illness to the world. "It must be told," she says.

Gertrude is thrice rejected. At 19 she bore a son to a boyfriend who soon left her, taking away the child. A second boyfriend got her pregnant in 1994 but disappeared in anger when their daughter was born sickly with HIV. A doctor told Gertrude it was her fault, so she blamed herself that little Noluthando was never well in the two years she survived. Gertrude never told the doctor the baby's father had slept with other women. "I was afraid to," she says, "though I sincerely believe he gave the sickness to me." Now, she says, "I have rent him from my heart. And I will never have another man in my life."

Gertrude begged her relatives to take her in, but when she revealed the name of her illness, they berated her. They made her the household drudge, telling her never to touch their food or their cooking pots. They gave her a bowl and a spoon strictly for her own use. After a few months, they threw her out.

Gertrude sits upright on a donated bed in a cardboard shack in a rough Durban township that is now the compass of her world. Perhaps 10 ft. square, the little windowless room contains a bed, one sheet and blanket, a change of clothes and a tiny cooking ring, but she has no money for paraffin to heat the food that a home-care worker brings. She must fetch water and use a toilet down the hill. "Everything I have," she says, "is a gift." Now the school that owns the land under her hut wants to turn it into a playground and she worries about where she will go. Gertrude rubs and rubs at her raw cheek. "I pray and pray to God," she says, "not to take my soul while I am alone in this room."

Women like Gertrude were brought up to be subservient to men. Especially in matters of sex, the man is always in charge. Women feel powerless to change sexual behavior. Even when a woman wants to protect herself, she usually can't: it is not uncommon for men to beat partners who refuse intercourse or request a condom. "Real men" don't use them, so women who want their partners to must fight deeply ingrained taboos. Talk to him about donning a rubber sheath and be prepared for accusations, abuse or abandonment.

A nurse in Durban, coming home from an AIDS training class, suggested that her mate should put on a condom, as a kind of homework exercise. He grabbed a pot and banged loudly on it with a knife, calling all the neighbors into his house. He pointed the knife at his wife and demanded: "Where was she between 4 p.m. and now? Why is she suddenly suggesting this? What has changed after 20 years that she wants a condom?"

Schoolteacher Syabusi is an educated man, fully cognizant of the AIDS threat. Yet even he bristles when asked if he uses a condom. "Humph," he says with a fine snort. "That question is nonnegotiable." So despite extensive distribution of free condoms, they often go unused. Astonishing myths have sprung up. If you don one, your erection can't grow. Free condoms must be too cheap to be safe: they have been stored too long, kept too hot, kept too cold. Condoms fill up with germs, so they spread AIDS. Condoms from overseas bring the disease with them. Foreign governments that donate condoms put holes in them so that Africans will die. Education programs find it hard to compete with the power of the grapevine.

THE CHILD IN NO. 17

In crib No. 17 of the spartan but crowded children's ward at the Church of Scotland Hospital in KwaZulu-Natal, a tiny, staring child lies dying. She is three and has hardly known a day of good health. Now her skin wrinkles around her body like an oversize suit, and her twig-size bones can barely hold her vertical as nurses search for a vein to take blood. In the frail arms hooked up to transfusion tubes, her veins have collapsed. The nurses palpate a threadlike vessel on the child's forehead. She mews like a wounded animal as one tightens a rubber band around her head to raise the vein. Tears pour unnoticed from her mother's eyes as she watches the needle tap-tap at her daughter's temple. Each time the whimpering child lifts a wan hand to brush away the pain, her mother gently lowers it. Drop by drop, the nurses manage to collect 1 cc of blood in five minutes.

The child in crib No. 17 has had TB, oral thrush, chronic diarrhea, malnutrition, severe vomiting. The vial of blood reveals her real ailment, AIDS, but the disease is not listed on her chart, and her mother says she has no idea why her child is so ill. She breast-fed her for two years, but once the little girl was weaned, she could not keep solid food down. For a long time, her mother thought something was wrong with the food. Now the child is afflicted with so many symptoms that her mother had to bring her to the hospital, from which sick babies rarely return.

She hopes, she prays her child will get better, and like all the mothers who stay with their children at the hospital, she tends her lovingly, constantly changing filthy diapers, smoothing sheets, pressing a little nourishment between listless lips, trying to tease a smile from the vacant, staring face. Her husband works in Johannesburg, where he lives in a men's squatter camp. He comes home twice a year. She is 25. She has heard of AIDS but does not know it is transmitted by sex, does not know if she or her husband has it. She is afraid this child will die soon, and she is afraid to have more babies. But she is afraid too to raise the subject with her husband. "He would not agree to that," she says shyly. "He would never agree to have no more babies."

Dr. Annick DeBaets, 32, is a volunteer from Belgium. In the two years she has spent here in Tugela Ferry, she has learned all about how hard it is to break the cycle of HIV transmission from mother to infant. The door to this 48-cot ward is literally a revolving one: sick babies come in, receive doses of rudimentary antibiotics, vitamins, food; go home for a week or a month; then come back as ill as ever. Most, she says, die in the first or second year. If she could just follow up with really intensive care, believes Dr. DeBaets, many of the wizened infants crowding three to a crib could live longer, healthier lives. "But it's very discouraging. We simply don't have the time, money or facilities for anything but minimal care."

Much has been written about what South African Judge Edwin Cameron, himself HIV positive, calls his country's "grievous ineptitude" in the face of the burgeoning epidemic. Nowhere has that been more evident than in the government's failure to provide drugs that could prevent pregnant women from passing HIV to their babies. The government has said it can't afford the 300-rand-per-dose, 28-dose regimen of azt that neighboring nations like Botswana dole out, using funds and drugs from foreign donors. The late South African presidential spokesman Parks Mankahlana even suggested publicly that it was not cost effective to save these children when their mothers were already doomed to die: "We don't want a generation of orphans."

Yet these children--70,000 are born HIV positive in South Africa alone every year--could be protected from the disease for about $4 each with another simple, cheap drug called nevirapine. Until last month, the South African government steadfastly refused to license or finance the use of nevirapine despite the manufacturer's promise to donate the drug for five years, claiming that its "toxic" side effects are not yet known. This spring, however, the drug will finally be distributed to leading public hospitals in the country, though only on a limited basis at first.

The mother at crib No. 17 is not concerned with potential side effects. She sits on the floor cradling her daughter, crooning over and over, "Get well, my child, get well." The baby stares back without blinking. "It's sad, so sad, so sad," the mother says. The child died three days later.

The children who are left when parents die only add another complex dimension to Africa's epidemic. At 17, Tsepho Phale has been head of an indigent household of three young boys in the dusty township of Monarch, outside Francistown, for two years. He never met his father, his mother died of AIDS, and the grieving children possess only a raw concrete shell of a house. The doorways have no doors; the window frames no glass. There is not a stick of furniture. The boys sleep on piled-up blankets, their few clothes dangling from nails. In the room that passes for a kitchen, two paraffin burners sit on the dirt floor alongside the month's food: four cabbages, a bag of oranges and one of potatoes, three sacks of flour, some yeast, two jars of oil and two cartons of milk. Next to a dirty stack of plastic pans lies the mealy meal and rice that will provide their main sustenance for the month. A couple of bars of soap and two rolls of toilet paper also have to last the month. Tsepho has just brought these rations home from the social-service center where the "orphan grants" are doled out.

Tsepho has been robbed of a childhood that was grim even before his mother fell sick. She supported the family by "buying and selling things," he says, but she never earned more than a pittance. When his middle brother was knocked down by a car and left physically and mentally disabled, Tsepho's mother used the insurance money to build this house, so she would have one thing of value to leave her children. As the walls went up, she fell sick. Tsepho had to nurse her, bathe her, attend to her bodily functions, try to feed her. Her one fear as she lay dying was that her rural relatives would try to steal the house. She wrote a letter bequeathing it to her sons and bade Tsepho hide it.

As her body lay on the concrete floor awaiting burial, the relatives argued openly about how they would divide up the profits when they sold her dwelling. Tsepho gave the district commissioner's office the letter, preventing his mother's family from grabbing the house. Fine, said his relations; if you think you're a man, you look after your brothers. They have contributed nothing to the boys' welfare since. "It's as if we don't exist anymore either," says Tsepho. Now he struggles to keep house for the others, doing the cooking, cleaning, laundry and shopping.

The boys look at the future with despair. "It is very bleak," says Tsepho, kicking aimlessly at a bare wall. He had to quit school, has no job, will probably never get one. "I've given up my dreams. I have no hope."

Orphans have traditionally been cared for the African way: relatives absorb the children of the dead into their extended families. Some still try, but communities like Tsepho's are becoming saturated with orphans, and families can't afford to take on another kid, leaving thousands alone.

Now many must fend for themselves, struggling to survive. The trauma of losing parents is compounded by the burden of becoming a breadwinner. Most orphans sink into penury, drop out of school, suffer malnutrition, ostracism, psychic distress. Their makeshift households scramble to live on pitiful handouts--from overstretched relatives, a kind neighbor, a state grant--or they beg and steal in the streets. The orphans' present desperation forecloses a brighter future. "They hardly ever succeed in having a life," says Siphelile Kaseke, 22, a counselor at an AIDS orphans' camp near Bulawayo. Without education, girls fall into prostitution, and older boys migrate illegally to South Africa, leaving the younger ones to go on the streets.

Every day spent in this part of Africa is acutely depressing: there is so little countervailing hope to all the stories of the dead and the doomed. "More than anywhere else in the world, AIDS in Africa was met with apathy," says Suzanne LeClerc-Madlala, a lecturer at the University of Natal. The consequences of the silence march on: infection soars, stigma hardens, denial hastens death, and the chasm between knowledge and behavior widens. The present disaster could be dwarfed by the woes that loom if Africa's epidemic rages on. The human losses could wreck the region's frail economies, break down civil societies and incite political instability.

In the face of that, every day good people are doing good things. Like Dr. Moll, who uses his after-job time and his own fund raising to run an extensive volunteer home-care program in KwaZulu-Natal. And Busi Magwazi, who, along with dozens of others, tends the sick for nothing in the Durban-based Sinoziso project. And Patricia Bakwinya, who started her Shining Stars orphan-care program in Francistown with her own zeal and no money, to help youngsters like Tsepho Phale. And countless individuals who give their time and devotion to ease southern Africa's plight.

But these efforts can help only thousands; they cannot turn the tide. The region is caught in a double bind. Without treatment, those with HIV will sicken and die; without prevention, the spread of infection cannot be checked. Southern Africa has no other means available to break the vicious cycle, except to change everyone's sexual behavior--and that isn't happening.

The essential missing ingredient is leadership. Neither the countries of the region nor those of the wealthy world have been able or willing to provide it.

South Africa, comparatively well off, comparatively well educated, has blundered tragically for years. AIDS invaded just when apartheid ended, and a government absorbed in massive transition relegated the disease to a back page. An attempt at a national education campaign wasted millions on a farcical musical. The premature release of a local wonder drug ended in scandal when the drug turned out to be made of industrial solvent. Those fiascoes left the government skittish about embracing expensive programs, inspiring a 1998 decision not to provide azt to HIV-positive pregnant women. Zimbabwe too suffers savagely from feckless leadership. Even in Botswana, where the will to act is gathering strength, the resources to follow through have to come from foreign hands.

AIDS' grip here is so pervasive and so complex that all societies--theirs and ours--must rally round to break it. These countries are too poor to doctor themselves. The drugs that could begin to break the cycle will not be available here until global pharmaceutical companies find ways to provide them inexpensively. The health-care systems required to prescribe and monitor complicated triple-cocktail regimens won't exist unless rich countries help foot the bill. If there is ever to be a vaccine, the West will have to finance its discovery and provide it to the poor. The cure for this epidemic is not national but international.

The deep silence that makes African leaders and societies want to deny the problem, the corruption and incompetence that render them helpless is something the West cannot fix. But the fact that they are poor is not. The wealthy world must help with its zeal and its cash if southern Africa is ever to be freed of the AIDS plague.