An inmate, well over six feet tall and garbed in an orange prison-issue jumpsuit, grips the thick iron chain linking the padlocked shackles encasing his ankles. With a white medical mask covering his lower face, the man is an arresting sight, but his menacing eyes discourage anything more than a quick glance from visitors.
The prisoner is one of a half-dozen shackled convicts under armed guard outside the HIV/AIDS clinic at Chris Hani Baragwanath Hospital in Soweto, South Africa. They have been brought here for treatment from Johannesburg (Diepkloof) Prison, a Dickensian horror of a jail nicknamed "Sun City" after South Africa's decadent gambling mecca. The mask on the glowering prisoner indicates he has infectious tuberculosis (TB), here the most deadly of the many opportunistic diseases associated with HIV, the human immunodeficiency virus, which causes acquired immunodeficiency syndrome, or AIDS. The pandemic–33.2 million people worldwide are HIV-positive and the disease has claimed more than 25 million lives since 1981–is acknowledged every December 1 on World AIDS Day. For those in Soweto, however, where the virus is omnipresent, every day is an AIDS Day.
The expression "on the frontline" is no more apt than when referring to Dr. Alan Karstaedt, director of the infectious-disease division in the department of medicine at Chris Hani Baragwanath Hospital, or Bara, as the locals refer to it. Bara is the only hospital in Soweto, an acronym for South West Townships. Soweto is famed as the heart of the anti-apartheid movement, when blacks fought the brutal, racist policies of the ruling white government from the 1960s to the 1990s.
Bara has the distinction of being the largest hospital in the world, serving the estimated 3.5 million souls, most of them Zulu, who reside in Soweto outside Johannesburg, South Africa's industrial hub. The hospital is, arguably, the epicentre of the planet's AIDS pandemic. About 20 percent of the population of South Africa–700,000 people in Soweto alone–have HIV/AIDS, while 35 to 38 percent of pregnant mothers test positive for the virus, Karstaedt says. The national infection number is at 5.8 million, and the South African Medical Research Council reports that 71 percent of deaths among those aged 15 to 49 are caused by the virus.
South Africa has the largest HIV-positive population in the world, according to the 2007 annual HIV/AIDS report released on November 20 by the Joint United Nations Programme on HIV/AIDS. According to the report, Southern Africa, where the country of South Africa is located, accounted for one-third of all new AIDS infections and deaths globally last year. In the past year there, 1.6 million people have died of AIDS.
Karstaedt, despite his position as department head and researcher, spends three days a week immersed in primary care, treating hundreds of the estimated 5,000 outpatients who are on antiretroviral (ARV) drugs, which diminish the effects of HIV and decreases the viral load. Today, Karstaedt ensures that the prisoners are treated ahead of the hundreds of men and women who have been queuing since early morning to be seen by HIV/AIDS clinic doctors. "We try to see the prisoners quickly; there have been a lot of escapes over the years," says Karstaedt, 54, who recalls the hospital's first diagnosed case of HIV in 1987: a Sowetan man suffering from cryptococcal meningitis.
Karstaedt has an air of exhaustion, with eyes so bloodshot his irises seem to be swimming in pools of red. The clinic is short-staffed today; there is only one other South African doctor and a tall Dutch physician with a blond ponytail; she seems unruffled by the cram of bodies. "The waiting area is designed for about 80 people, but up to 300 people will come in," Karstaedt says with the same resignation that his patients show during their vigil.
The waiting room is hot and claustrophobic. Patients are not only on ARVs but are being treated for a variety of AIDS-related diseases, ranging from infectious TB to bacterial pneumonia or cryptococcal meningitis. For multidrug-resistant TB, a bacterial strain impervious to antibiotics, the hospital's only disease-control measure is to "keep the windows open", Karstaedt says.
The clinic operates beyond capacity. Last year it went double over its budget of 20 million rand, or approximately $3 million. There is no fat to cut. Patients are responsible for their own medical files, which they must bring to the clinic. There is not enough money for a proper filing system or computers. Counselling exists thanks to NGOs. The waiting time to see patients is three to four weeks, although the very ill are fast-tracked. At its worst, Bara had a waiting list of six months: two to three months for an appointment and another three months to have a prescription filled. "The pharmacy was backed up," Karstaedt explains dryly.
A tiny handful of HIV/AIDS clinics have opened in Soweto, but the care is inconsistent, dependent upon the experience of the clinic doctors and nurses and how well they recognize "toxicities and other problems", Karstaedt says.
Bara hospital had 33,000 admissions last year; a significant proportion of these were due to HIV/AIDS, Karstaedt says. In comparison, the immunodeficiency clinic at the British Columbia Centre For Excellence in HIV/AIDS, located at St. Paul's Hospital in Vancouver, has 900 registered patients while the hospital's AIDS ward had 453 admissions during the 2006-2007 fiscal year. The centre has an annual budget of $75 million.
At Baragwanath, some estimate that up to 50 percent of those admitted are HIV-positive. Karstaedt errs on the side of caution. There is no proof of this, he says, because many patients, even though they are ill with diseases associated with HIV, refuse to be tested for the virus.
Despite such challenges, there are incredible success stories, especially since the government program of free, generic ARV drug distribution began in April 2004, Karstaedt says. Patients, skeletal from illness, gained 40 to 50 kilograms. They returned to school, work, running marathons, or performing with professional dance troupes, he notes. They were able to parent their children.
Toronto's Zaida Bastos, Africa program coordinator for the Primate's World Relief and Development Fund, one of many faith-based organizations helping fight HIV/AIDS in Africa, believes that the infection rate in Soweto is creeping toward 50 percent. At one medical clinic in the Kingsway district of Soweto, 728 new patients this past year were tested for HIV; 638 were positive, Bastos says.
"It is a delusion to say it isn't rising," says Bastos, who was in Soweto to assess a community-based HIV/AIDS palliative-care project that the Anglican Church of Canada helps support through its PWRDF.
ARV drugs are not the panacea that a still-elusive vaccine would be. In the West, however, advances with ARV drugs have made HIV/AIDS a manageable, if chronic, disease, with patients living for decades. But in South Africa, the dearth of medical staff and clinics prevents many of those with HIV/AIDS from receiving ARVs. About 200,000 people are on the drugs; Karstaedt says that 500,000 people should be on ARVs.
Although thousands of people with HIV/AIDS receive treatment at Baragwanath, that care is compromised by poverty. Hilda Dube is a 54-year-old Zimbabwean woman who came to Soweto in 1989 with her husband, who left her to marry another woman. Dube was diagnosed as HIV–positive this past July after she became ill with TB. Her community-based palliative-care worker, Mabel Mashego, comes to her tiny shack every morning to ensure that Dube, who is often disoriented, takes her medication. Dube has no money, so Mashego brings her food when she can.
Dube's black hair sticks straight up in wild strands and her cloudy brown eyes leak tears. She sits hunched on her old black leather couch, which sprouts stuffing. A single four-by-four braces the corrugated-iron roof that covers her tiny shed in Doornkop shantytown, one of many scrap-wood shack communities in Soweto that the government euphemistically calls "informal settlements". Dube is emaciated; the flesh hangs off her arms like empty leather water skins. But her body balloons at the belly and her legs and feet are so painfully swollen she can barely shuffle outside to use the metal bucket in the collapsing outhouse.
Mashego says that the TB medication is causing the swelling, and Dube must go to hospital for treatment. Dube holds her hands out in defeat. "Twenty rand," she says, referring to the cost of taking a taxi one way to Baragwanath. R20 equals $3. Because she can barely walk, Dube will need to pay the taxi fare of a neighbour who can accompany her. The total cost: R80, or $12. For Dube, who is ineligible for government assistance because she is not a South African resident, R80 is a king's ransom.
Poverty afflicts not only the unemployed but professionals as well. This past June, the Congress of South Africa Trade Unions, which includes hospital workers among its members, embarked on the largest strike since apartheid ended in 1994. At Baragwanath, a skeleton crew ran the emergency department, taking in only 100 patients a day, down from the usual 500. Doctors from other departments were too intimidated by strikers to come to work.
For the patients dependent upon Baragwanath, it was a disaster. Sheila Nte, 38, has been on ARVs for HIV/AIDS since 2006, and was employed in the marketing department at an upscale Johannesburg hotel. Then she was hit by a car while crossing a road. The strike meant she could not access medical help. A private-clinic visit would have cost Nte at least R2,000 ($300), which she couldn't afford. Nte gradually became more incapacitated and lost weight. By the time she was able to see a doctor, two months after the start of the strike, she was down to 48 kilograms and couldn't walk. Doctors first sent her for X-rays. Then, an astute physician diagnosed TB of the spine, caused by HIV/AIDS. The TB onset was coincidental with the car accident. Nte grasps at small victories. "I can stand alone, but I walk like a duck," she says in a brave attempt at humour, shuffling a few steps while her mother, with whom she lives, watches with concern. "I have a mission to get better," Nte says. "This is not the end of my story."
Hope and optimism are often the best, and sometimes the only, weapons against HIV/AIDS, which has afflicted two generations of South Africans and is poised to strike a third.
With HIV/AIDS, ignorance is the enemy. Soweto is a place of single-parent households and high unemployment. AIDS orphans–many of whom live on the streets–and children with parents who are sick or unemployed don't attend school, so they miss the messages of condom use, self-respect, and respect for others that are hammered into students from the early grades.
But the traditional patriarchal society is also at fault; it is difficult to shift the mores of an ancient culture. The Zulus dominating Soweto uphold polygamy. Men tend to have, at the very least, a wife and two or three girlfriends. Condom use is considered unmasculine. Poverty allows such male hubris to flourish, as women often depend upon their boyfriends for money to buy food.
"Women aren't employed; they are economically dependent upon men and will accept behaviour from them that they wouldn't if they were economically independent," Bastos says. "It's a question of survival."
Men in South Africa are also notoriously reluctant to be tested for HIV, fearing social stigma. At one clinic, 15,000 women came to be tested, while only 1,714 men were, Bastos says. "Men are part of the problem; they must be part of the solution."
For people like Dr. Karstaedt, a solution to the daily onslaught of disease is far, far away. What does World AIDS Day mean to him? "There have been many years of AIDS Days," Karstaedt muses. "The results are not concrete for this hospital."