A tragedy far beyond human understanding

AFRICA is suffering a Malthusian tragedy of famine, war, poverty and diseases, including Aids, malaria and tuberculosis. There are some historic tragedies which are so terrible that it is almost impossible to comprehend them. That is true of the Holocaust, the destruction of European Jewry by the Nazis. The African tragedy is on the same scale.

In sub-Saharan Africa, famine, war and disease are widespread, but the Aids pandemic, much worse than that in Europe or North America, is going to destroy up to a quarter of the population. The situation is bad enough in the rest of the world; in Africa, the spread of the infection has already reached the stage at which casualties will be greater than in any epidemic since the Black Death. If Dr Jonathan Mann, of Harvard University, is right in saying that 'the global epidemic is out of control', then in Africa, it is exploding.

The leading British scientist studying the demographic implications of the pandemic is Professor Roy Anderson, of Imperial College, London. He published a paper in Nature last year in which he reported that his team's computer models forecast major demographic changes resulting from Aids in some African countries. In June, he elaborated these projections at an international conference in Nairobi. His projections show that the population of some African countries could begin to fall before the end of the century. The Harvard School of Public Health supports these forecasts with its current estimate that the number of Africans infected with HIV has trebled in the past five years to about 7.5 million.

The Anglo American Corporation of South Africa, the major multinational mining group, has commissioned a variety of research documents that also tend to confirm Roy Anderson's and Jonathan Mann's work.

Particularly significant findings are those of Peter Doyle, for the South African Society of Actuaries. Relatively speaking, Mr Doyle is an optimist. His model suggests that HIV infection in South Africa will eventually level off at 27 per cent of the adult black population by the year 2005. Other models give higher figures.

This may be regarded simply as another projection, and many others have proved mistaken in the past. When one compares Mr Doyle's projections with actual levels in other sub-Saharan countries, one can, however, see a ladder of progression. The level in Malawi has already topped 25 per cent, at least in women tested in antenatal clinics. Zambia had reached 25 per cent by 1990, and Uganda was at 22 per cent by 1989.

Burundi, Tanzania, Rwanda and Zaire are also in the group where a quarter or more of the adult population may now have been infected with HIV. As the infection passes more easily from men to women than from women to men, a small majority of those infected are probably women. Obviously, estimates of HIV infection are imprecise, but there have been sufficient public tests to indicate the order of magnitude.

A further group, including the Central African Republic, Ghana, Zimbabwe, Angola, Kenya and Mali, is likely to reach the same high infection level by the mid-Nineties. South Africa is among the slowest starters, together with countries such as Nigeria, but all are following approximately the same trends.

Peter Doyle has done a special study of the likely impact on the 450,000 mine workers in South Africa. In 1990, he estimates, 2,615 new cases of HIV infection occurred among them; he expects that to increase to 7,207 this year, to 15,227 in 1994 and to a peak of 19,278 in 1996. This will then gradually decline to an endemic rate of about 14,000 by the year 2010. Aids deaths follow the same pattern with about a seven-year time lag. They will reach, on this model, 9,000, or 2.5 per cent, by the year 2003. A quarter of the whole workforce of miners will have died of Aids by the year 2009.

There is little prospect of change in these trends in the next 10 years. Worldwide scientific work is producing a better understanding of the disease, but the process of devising a vaccine or medical remedies is slow and fitful.

Education does help. Even in Africa, where condoms remain very unpopular, they are increasingly used. In the worst-affected areas, perhaps one condom in 3,000 will prevent a woman being infected who otherwise would have been. Reduction in the number of partners is achievable even among those who will never practise monogamy.

Young women can be taught to fear being infected by old men - that goes with the grain of nature - and old men are a common source of infection for younger women in Africa. Above all, a strong taboo can be created against those who know themselves to be infected engaging in unprotected sex.

Yet the bleak truth remains. In several countries in Africa, a quarter to a third of the population is already infected with HIV. There is no epidemiological reason to suppose that those levels will not be reached throughout most of sub-Saharan Africa. Tuberculosis is the commonest secondary disease of Aids in Africa, affecting about a third of Aids cases and spreading into the general population. Malaria is also on the increase, partly because of resistance to drugs, partly because of the breakdown of anti-mosquito controls.

Apart from South Africa, the African nations are poor and vulnerable societies. The people dying include many of the best educated and ablest, and many of the mothers.

One can quote Foster and Lucas, Socioeconomic Aspects of HIV and Aids in Developing Countries, 1991: 'Women are the main producers of food in many African communities, as well as the primary care-givers. Death of the mother may result in children being sent to live with their grandparents (most often a widowed grandmother), which represents in some cases several steps back in development and in possibilities for the children.' Aids is reversing all the positive trends in African life.

There is the threat that the disease will follow a similar course in other parts of the world, particularly in India and South-east Asia. It could also follow the same course in the poor black ghettos of North America, where the sexual culture, including prostitution, surrounding crack cocaine is regarded as the main reason for the extraordinary rise in Aids and other sexually transmitted diseases.

As people take more sexual partners, so the spread of Aids is helped, as are other sexually transmitted diseases. African cultural patterns, like those of Thailand or the American ghettos, have always been conducive to the spread of sexual diseases. Even so, Peter Doyle estimates that 30 per cent of the population is not at risk. This part of the population will continue to grow, and may reach 50 per cent in many African communities by the year 2010. If the high-risk group is now 70 per cent, and 25 per cent is infected, that means more than a third of the high-risk group will die in each generation.

Aids is already the leading cause of death in some African countries. The director of the World Health Organisation's Global Programme on Aids, Dr Michael Merson, has observed that the West thinks it has been in this pandemic for 10 years, 'but we've only been in the HIV pandemic. Now we're entering the Aids pandemic and we'll be in this for at least 30 to 50 years, assuming the growth curve comes down because people practise safer sex.' That, indeed, is a tragedy beyond human understanding.