“What do you mean?” he asked. “In terms of him leaving Lusikisiki? In terms of the health of the people?”
“Both of those things.”
“Maybe he left because he was getting bored of living among the black people,” Sizwe said. “That is fine, it is his choice. But the way he left was wrong. He should have found another white doctor to replace him. Or not even a white. Just somebody who is gentle with the people. Because the black nurses are so cruel to sick people. You go there with AIDS and they shout at you. Even Nwabisa is scared to go to the clinic with Mfanawetu. She went to take him the other day because he had worms. And the nurse shouted at her: ‘How can you allow your son to get worms!’ You come away from the black nurses and you are feeling ashamed of yourself.
“So it is okay that he left, but he should have found someone like him to replace him.”
“You no longer believe, then,” I asked, “that he is part of the conspiracy of the umlungus to kill the blacks? He is not one of those who knows of the cure for AIDS but holds it back?”
“No,” he replied. “He wants to do good with those pills. He is not part of the plot. He doesn’t even know about it.”
THERE IS NO particular reason why Hermann Reuter should stand as an emblem of the quest to heal a country of AIDS. Nor is there a special reason Sizwe’s response should reflect that of ordinary people across South Africa. But these are the people I have found through whom to tell a story of AIDS treatment, and it is hard to stop myself from thinking of them allegorically.
On this stage, one I have erected, there are two figures. The doctor expresses his frustration with those who will not be patients. During moments of weakness, his frustration becomes an accusation, a rejection, a washing of the hands. As for the other figure, he has, despite his initial suspicions, come to see the doctor as a good soul and a healer. But a healer in the limited way of a Florence Nightingale, stitching and bandaging the victims for all his worth—while out of sight, in the war rooms of the powerful, more carnage is being planned.
Epilogue
Late one evening at the end of April 2007, I phone a woman named Sharon at her home in the middle-class suburbs of Port Elizabeth. We have spoken just once before, about a year ago. I had made contact with her to ask about a bird-watching trip she, her husband, Graeme, and a party of amateur ornithologists had done on the Pondoland coastline in December 2003. I wanted to talk about the young man, Sizwe Magadla, who had guided the party through the coastal forests, and how it came about that they decided to capitalize his new business venture.
She was pleased that I had called, and for the better part of an hour she spoke warmly of Sizwe: of his breathtaking knowledge of the forest and its fauna; of the attractiveness of his curiosity, at once penetrating and unobtrusive; of how for months after the trip nobody in the party had been able to shake him out of their thoughts.
Now, a year later, she does not wait to hear why I have called again.
“It is so strange that you phone now,” she says. “Just last week I had a long conversation with Sizwe, our first in ages. He kept me for nearly two hours. He was very agitated. It was partly about you.”
“What’s the matter?” I ask.
“He said you came to see him a couple of weeks ago, and that you needed to know why he would not test for HIV. Your conversations left him disturbed. He told me he needed to test, that it was keeping him up every night, but that he was scared.”
“What did you say?”
“Well, throughout the conversation, his wife was in the room listening. And I said to him, ‘You are sharing all this fear with the woman in your life. You clearly love and trust one another so much. Your world cannot collapse around you. Nwabisa is there.’ I told him that if he wanted, he and his wife and child should get on a bus and come; that he should test here, that they could stay with us for as long as they wanted.”
“What did he say?”
“That he’d think about it.”
I PHONE SIZWE the next morning. We speak about this and that. We have never communicated well on the phone. Our stilted exchange seems a bad context in which to tell him about my conversation with Sharon. I am about to say good-bye and hang up.
“Wait,” he says. “I went to Village Clinic in town last week. I went for them to test me.”
He pauses a long time.
“And?”
“They had no electricity, no running water. It was so crazy there. I waited until after lunchtime. Then I went home.”
“But you went back?”
“Yes. Two days later. It was still dark in there. I waited until after lunch again. They couldn’t test me.”
“The electricity is back now, surely?”
“I don’t know.”
“I’m sure it’s back.”
He chuckles, affectionately, but mockingly. He is laughing at my earnest concern.
“Maybe,” he says. “We will see.”
But the lightness in his tone suggests that the urgency of his need to know has passed. The restless fear that caused him to phone Sharon out of the blue and ask for help, the agitation that had taken him away from work for two days to sit in a clinic waiting room, these are things from last week; they are gone now. Mfanawetu’s plaintive voice pierces our conversation.
“I am keeping you from your son,” I say. “I can hear that he wants to play with you.”
His laughter is even lighter this time. “No. He is playing with some other children, and with a dog. They are all together on the floor. They are all happy.”
“And so are you.”
“I am very well,” he says. “Everyone here is very well.”
I PUT DOWN the phone and think of Hermann Reuter. He is right. Sizwe went to test and couldn’t. The problem was not one of demand for health care but of supply. “People arrive at a health-care facility frightened and unsure,” Hermann told me a few months before MSF left Lusikisiki. “If you turn them away, they will not come back.”
I discover subsequently that there is no electricity because the clinic has not paid its utilities bill and the municipality has cut its services. When Hermann came to Lusikisiki he fought bitterly to have electricity installed at the clinics. I cannot say for sure, but if he had still been around I doubt that the bill would have remained unpaid. The darkness is one of the many symptoms of a treatment program that has lost its champion. Perhaps other champions will come.
But Sizwe’s failure to test is not simply a tale about health-care services: it is a tale about men.
ON THE DAY of our telephone conversation, some 262,000 people have begun antiretroviral treatment at public health-care facilities in South Africa. More than two-thirds of them are women. Why? Where are the missing men? Why are they so less likely to find their way to ARV treatment than women?
That is not a question I set out to answer when I began writing this book, but it has been hard not to notice it on almost every page. It is unlikely that Sizwe is among the missing men; in all probability, he has the immunity of a healthy thirty-one-year-old. But when he speaks of his reluctance to test and of his conviction that were he to fall ill and take the pills they would only remind him that he is dying, he is speaking not just for himself but also for the missing men. When he expresses terror it is their terror he is expressing.
The sociologist Deborah Posel has written that with the AIDS epidemic “sex itself has become the vector of death…[I]t is the very intimacy of the home—mother, father and children—which has become contaminated. And it is men particularly—the fathers and sons of the nation—whose moral credibility is most acutely called into question.”
There are few men left in Lusikisiki who do not know where to go to be treated for AIDS. That is the considerable accomplishment not only of Médecins Sans Frontières but of the social movement for AIDS treatment that has arisen in postapartheid South Africa. Tens of thousands of men have benefited from this movement, but only a tiny minority will ever join it. Most will never mak
e of ARVs a right for which they will fight, or of HIV the substance of their self-assertion. They are too ashamed. To embrace lifelong treatment, men like Sizwe need something else entirely.
On our car journey to Mount Ayliff in early April 2007, Sizwe told me that his relation to white people was mercenary. And yet the events leading to his attempt to test belie a far more complicated story. When he needed finally to confront the prospect of dirt in his blood, it was to the bird-watchers he turned, people whose place in his world is so unheralded and strange as to be ghostly. Why?
Perhaps precisely because they are of another place. By the accident of their social and physical distance, they had become equivalents of the benign figure Kate Marrandi so skillfully carved. Kate filed away at herself until she was no longer of and in her world—no sexual history, nothing to rival, nothing to envy, nothing to reflect hostility or shame back at you. For Kate, another person was only a life to hold and to preserve. The bird-watchers are not of Sizwe’s world. Because of what they gave him, they are merely the bearers of an extraordinary gift, a wondrous embodiment of his life interests.
Perhaps Kate and the bird-watchers are a model of the place the missing men might dare enter to be treated; a place sufficiently detached from the thick of the world to have become absolutely safe; a place where one might find the means to stay alive.
Notes
“People are too scared”: Edwin Cameron, Witness to AIDS (London: IB Tauris, 2005), p. 67.
About 2.1 million people died: UNAIDS, “AIDS epidemic update, December 2006,” p. 13, http://www.unaids.org/en/HIV_data/.
A new democracy is an era of resurging life: This idea of AIDS as an attack on both the individual’s and the nation’s generative powers was originally made by sociologist Deborah Posel. See her “Sex, death, and the fate of the nation: Reflections of the politicization of sexuality in post-apartheid South Africa,” Africa 75, no. 2 (2005): 125–43.
“If when the dogs bark”: Monica Hunter, Reaction to Conquest: Effects of Contact with Europeans on the Pondo of South Africa (1936; rept. London: Oxford University Press, 1961), p. 351.
“The values they preach and largely practise”: Philip Mayer and Iona Mayer, “Report of Research on Self-Organisation by Youth among the Xhosa-Speaking Peoples of the Ciskei and Transkei,” Pretoria, Human Sciences Research Council, 1972, p. 127.
“a strange, whistling kind of language”: Jeff Peires, The Dead Will Arise: Nongqawuse and the Great Xhosa Cattle-Killing of 1856–7 (1989; rept. Johannesburg and Cape Town: Jonathan Ball, 2003), p. 113.
“They often incited whispers that the ‘long needle’ of the White man”: Benedict Carton, “The Forgotten Compass of Death: Apocalypse Then and Now in the Social History of South Africa,” Journal of Social History 37, no. 1 (2003): 204.
“The women say [the doctor and the anthropologist] have used our blood against us”: Wulf Sachs, Black Hamlet (1937; rept. Johannesburg: Witwatersrand University Press, 1996), p. 210.
In the Kenyan city of Mombasa, it was widely believed that the fire department captured Africans: Louise White, Speaking with Vampires: Rumor and History in Colonial Africa (Berkeley: University of California Press, 2000), pp. 3, 102.
“The authorities ordered vaccination”: Joseph Roth, Job, translated by Dorothy Thompson (Woodstock, N.Y.: Overlook Press, 2003), pp. 8–9. (Roth’s book was first published in German in 1930.)
“Thousands flocked to the clinics from all over the southeast”: Terence Ranger, “Godly Medicine: The Ambiguities of Medical Mission in Southeastern Tanzania,” in Steven Feierman and John M. Janzen, eds., The Social Basis of Health and Healing in Africa (Berkeley: University of California Press, 1992), p. 264.
“The gay past is not pure”: Colm Tóibín, Love in a Dark Time: Gay Lives from Wilde to Almodóvar (London: Picador, 2002), p. 14.
“Their manner seems to say”: Isaac Bashevis Singer, In My Father’s Court (1962; rept. New York: Farrar, Straus & Giroux, 2000), p. 186.
The areas doing well were those where “HIV care initiatives had existed”: Helen Schneider, “Reflections on ART policy and its implementation: Rebuilding the ship as we sail?” Acta Academia Supplementum 1 (2006): 27.
“sex itself has become the vector of death”: Posel, “Sex, death, and the fate of the nation,” p. 92.
Further Reading
The following books and articles are here for one of two reasons: they helped me to shape aspects of this book, or they are my recommendations for further reading.
I know of only one general history of the African AIDS epidemic—John Iliffe’s The African AIDS Epidemic: A History (Oxford: James Currey, 2006)—and found it extremely valuable. The question of why the AIDS epidemic has been uniquely terrible in Africa has produced many rival answers both reasonable and unreasonable. Iliffe’s book contains an incisive commentary on the debate. Of the scholars who have weighed in on the debate, I have learned much from Eileen Stillwaggon, AIDS and the Ecology of Poverty (New York: Oxford University Press, 2006), and Helen Epstein, The Invisible Cure (New York: Farrar, Straus & Giroux, 2007). Stillwaggon and Epstein agree on almost nothing; their divergence tells a good deal about the scale of controversy.
On the coming of antiretroviral treatment to Africa: Anne-Christine d’Adesky, Moving Mountains: The Race to Treat Global AIDS (New York: Verso, 2004); Greg Behrman, The Invisible People (New York: Simon & Schuster, 2004); Stephen Lewis, Race Against Time (Toronto: House of Anansi Press, 2005). On the struggle for antiretroviral treatment in South Africa: Edwin Cameron, Witness to AIDS (London: IB Tauris, 2005); Nicoli Nattrass, Mortal Combat (Durban: University of KwaZulu-Natal Press, 2007); Steven Robins, “Long Live, Zackie, Long Live!” Journal of Southern African Studies 30, no. 3 (2004): 651–72.
As Hermann Reuter’s various soliloquies at the beginning of Part Two of this book make clear, there is a lengthy debate in progress on the economic efficacy of ARVs in Africa. Can the continent afford to put and keep the ill on drugs? Would the money not be better spent on interventions that lower the rate of new infections? The literature on these questions is vast. To get a sense of the terms of the debate, see an exchange between Richard Cash and Nicoli Nattrass that took place at Princeton University’s Center for Human Values in April 2006 at http://www.princeton.edu/~uchv/archive/2005calendar.html.
The most persuasive and articulate defender of Hermann Reuter’s view that the demand for health care is a function of its supply is Paul Farmer. See Paul Farmer, AIDS and Accusation: Haiti and the Geography of Blame (Berkeley: University of California Press, 1992); Paul Farmer, Infections and Inequalities: The Modern Plagues, 2nd edition (Berkeley: University of California Press, 2001); Paul Farmer, Pathologies of Power: Health, Human Rights, and the New War on the Poor, 2nd edition (Berkeley: University of California Press, 2005). See also Tracy Kidder, Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure The World (New York: Random House, 2003).
Barrels of ink have been spent on South African president Thabo Mbeki’s views on AIDS. Two books tower above the rest: Mark Gevisser, Thabo Mbeki: The Dream Deferred (Johannesburg: Jonathan Ball, 2007), chapter 41; and Didier Fassin, When Bodies Remember (Berkeley: University of California Press, 2007).
On AIDS stigma in South Africa, the scholar I have learned from most is the sociologist Deborah Posel. Her work on stigma is part of and should be read together with a broader project on sexuality in postapartheid South Africa. See Deborah Posel, “Sex, Death and Embodiment: Reflections on the Stigma of AIDS in Agincourt, South Africa,” paper for symposium on Life and Death in a Time of AIDS, The Southern African Experience, WISER, Johannesburg, October 14–16, 2004; Posel, “Sex, death, and the fate of the nation: Reflections of the politicization of sexuality in post-apartheid South Africa,” Africa 75, no. 2 (2005); Posel, “‘Baby rape’: Unmaking secrets of sexual violence in post-apartheid South Africa,” in Graeme Reid and Liz Walker, eds., Men Behaving Differently: South African Men since 1994 (Cape Town: Double Store
y, 2005), pp. 24–63.
The historians Peter Delius and Clive Glaser have produced a wonderful survey of anthropological and historical scholarship on sexuality in South Africa. See Delius and Glaser, “Sex, disease and stigma in South Africa: Historical perspectives,” African Journal of AIDS Research 4, no. 1 (2005): 29–36; Delius and Glaser, “The Myths of Polygamy: A History of Extra-Marital and Multiple-Partnership Sex in South Africa,” South African Historical Journal 50 (2004): 84–114; Delius and Glaser, “Sexual Socialisation in South Africa: A Historical Perspective,” African Studies 61, no. 1 (2002): 27–54.
On the political economy of sex in contemporary South Africa, Mark Hunter’s work is unsurpassed. See Hunter, “Zulu-speaking Men and Changing Households: From providers within marriage to providers outside of marriage,” in Benedict Carton, John Laband, Jabulani Sithole, eds., Being Zulu: Contesting Identities Past and Present (London: Hurst; Pietermaritzburg: University of KwaZulu-Natal Press, forthcoming); Mark Hunter, “Informal Settlements as Spaces of Health Inequality: The Changing Economic and Spatial Roots of the AIDS Pandemic, from Apartheid to Neoliberalism,” Durban, University of KwaZulu-Natal, Centre for Civil Society Research Report no. 44, 2006; Mark Hunter, “Cultural Politics and Masculinities: Multiple Partners in Historical Perspective in KwaZulu-Natal,” in Culture, Health and Sexuality 7, no. 4 (July 2005): 389–403; Mark Hunter, “The Changing Political Economy of Sex in South Africa,” Social Science and Medicine 64 (2007): 689–700; Mark Hunter, “The Materiality of Everyday Sex: Thinking beyond ‘prostitution,’” African Studies 61, no. 1 (2002): 99–120.
On mourning and the feeling of triumph in the living over the dead, see Melanie Klein’s essay “Mourning and its relation to manic-depressive states,” in Klein, Love, Guilt and Reparation and Other Works, 1921–1945 (London: Hogarth, 1975), pp. 344–69. See also the two Freud papers on which Klein based her essay: Sigmund Freud, “Mourning and Melancholia,” in Freud, On Metapsychology: The Theory of Psychoanalysis, trans. James Strachey, ed. Angela Richards (London: Penguin, 1991), originally published in German in 1917; and Freud, “Our Attitude Towards Death,” in Freud, Civilization, Society and Religion, trans. James Strachey, ed. Albert Dickson (London: Penguin, 1987), originally published in German in 1915. In thinking about Sizwe’s quest for permanence through generativity I was helped a great deal by Philippe Ariés’s classic studies of death: The Hour of Our Death, trans. Helen Weaver (London: Allen Lane, 1981); and Ariés, Western Attitudes Towards Death From the Middle Ages to the Present, trans. Patricia M. Ranum (Baltimore: Johns Hopkins University Press, 1974). Closer to home, discovering the work of the South African anthropologist Hylton White was both validating and enlightening. See, in particular, Hylton White, “Ritual Haunts: The Timing of Estrangement in a Post-Apartheid Countryside,” in Brad Weiss, ed., Producing African Futures: Ritual and Reproduction in a Neoliberal Age (Leiden: Brill, 2004).
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