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A Never-ending Tragedy — The Onset of the AIDS Crisis in Africa

The spread of AIDS in Africa in the 1980s and 90s presented unique challenges for U.S. diplomats suddenly faced with a public health epidemic. Not only did local hospitals and medical resources become overrun, diplomatic communities and Americans living abroad were threatened by the emergence of HIV/AIDS. While countries such as Uganda implemented crucial AIDS education and prevention policies early on, other nations were slower to address the problem and as a result witnessed the death of entire villages.

Ambassador Robert Gribbin was Deputy Chief of Mission (DCM) in Kampala, Uganda at the height of the country’s AIDS outbreak from 1988 to 1991. Interviewed by Stu Kennedy, he describes arriving as DCM to a country already devastated by the disease. As Deputy Assistant Secretary for sub-Saharan Africa, Prudence Bushnell dealt with fallout from the AIDS epidemic in Africa from 1993-1995. Stevenson McIlvane served as Deputy Chief of Mission (DCM) in Lusaka, Zambia from 1995-1998 and observed the effect of AIDS on local employees as well as the American embassy community. Read more about Deputy Assistant Secretary Bushnell in her accounts of the Embassy Nairobi bombings and the Rwandan genocide. You can read Ambassador Gribbin’s account of the genocide.


“AIDS was a never-ending tragedy”

Deputy Chief of Mission Robert Gribbin

GRIBBIN: AIDS was the enormous social problem. Although we were just beginning to learn about it, AIDS was well advanced. The Ugandan Government deserves credit for being very forthright in looking at the problem and in devising ways to address it. Essentially, AIDS probably first broke into a pandemic in Uganda, in the district of Rakai, to the south of Kampala, near Lake Victoria.

By the time I arrived in 1988, there were tens of thousands of orphans in Rakai District who had lost one or both of their parents. Organizations like Save the Children were involved in trying to hold families together. A key problem was that no one was left to grow food. Grandmothers couldn’t do it. They might have 15 children in their care when they ought to be free from such responsibilities and farm work. The AIDS problem was real, and was also afflicting the people of Kampala. The infection rate among the adult population in Kampala rose to almost 30 percent.

In a heterosexually promiscuous society, which most modern African societies are, AIDS spreads rapidly. In Uganda it initially traveled along the truck routes, transmitted between prostitutes and truck drivers. Soldiers too caught the virus and brought it home. In the cities, older men would often seek out younger women or prostitutes. They would get infected and bring the disease home. The challenge in Uganda was to change people’s sexual behavior. Concerned individuals and organizations began a very concerted program to do that. I remember seeing the minister of health standing in the streets of the marketplace holding up condoms and telling people what they were for. The blood bank was cleansed and national HIV testing offered. Survivors joined together for support and to counsel those infected.

In my spare time, I was a member of the Mountain Club of Uganda. The club grouped a few expatriates along with younger Ugandans – Makerere University students and graduates – who enjoyed rock climbing, mountain climbing and hiking. For example, each year we climbed to the highest peak of the Ruwenzori mountains. Of my friends in the Mountain Club, at least five that I could name right now subsequently died of AIDS. Sadly, they never had a life, never a career or a family.

It was also tragic for the embassy. About a half dozen of our FSNs [Foreign Service Nationals] died of AIDS in the three years I was there.

I worried about AIDS. We conversed with medical personnel in the State Department. We adopted what was called a “walking blood bank,” where the participant’s blood type was known. If your blood were needed, you’d fill out a questionnaire regarding your recent behavior. Your answers included or excluded you from being a blood donor.

As DCM I was most worried about the Marines, and when we re-established the Peace Corps program, I worried about volunteers. In fact, we thought long and hard about re-opening the Peace Corps precisely because of the AIDS menace to volunteers. I used to call each newly arrived Marine into my office and give him the good old Dutch Uncle lecture, but you know, when you’re 19 that may not always work. I kept a box of condoms on the safe in my office. I would tell the Marine. “There they are. Nobody’s going to see you take some. When you’re in here checking locks at night, help yourself.” I always had to keep filling up that box. That worried me, but it would have worried me more if the box were never touched.

We changed our local employee compensation plan, particularly the death benefits portion of it, because under Ugandan practice, by and large, when a male died, the man’s family inherited his assets, not his wife and children. Presumably, one would die at a reasonably elderly age, so grown children would be capable of taking care of themselves and their mother. But if a man died at a young age, then no one took care of his spouse and the children. Additionally, the spouse was probably AIDS-infected as well and on her way to dying. Our local employees knew that if someone died, oftentimes the man’s family would clean out his house, take the family possessions and throw the wife and children into the street. It sounds callous, but in fact that’s what happened. So our FSNs asked that we put together a system whereby the embassy would parcel out death benefit payments over time and only to the spouse and only in a manner whereby her husband’s relatives could not get their hands on it. We made those sorts of adjustments. AIDS was a never-ending tragedy.

Ugandans would jump at every hope. I remember a woman near Masaka, a town to the south, who announced to the press that her daughter was cured of AIDS because she had eaten clay from the back yard. In short order, convoys of cars and buses took dozens of people to eat the dirt from this lady’s back yard. This went on for about three or four months until the lady’s daughter died of AIDS. Then people concluded that the remedy wasn’t effective. I asked people about this, intelligent people, even once somebody who did it. He said, “Well, it might work, you don’t know.” Victims clung to whatever hope they could muster.

Let me relate a story about Ugandans changing their sexual behavior. It was clear that part of the solution to reducing infections was to limit sexual partners. In that regard Ugandans became very fond of using the term, in public, in the media and in speeches by the president, of “zero grazing.” As a cattle-keeping society they understood zero grazing to mean that one didn’t go into somebody else’s pastures, but the zero also came from the fact that to zero-graze a cow, you put a rope around her neck and tie her to a stake. She can only eat in a circle. That’s her zero and she’s always tied to the stake.

Ugandans implicitly understood this metaphor right away and it quickly became part of daily discourse. I’m pleased to say now in 2000 that Uganda has made substantial inroads in changing people’s sexual behavior. The incidence of new AIDS infection in Uganda is falling – the only place in the world where that’s happening. Sadly, the people who were already infected either have died or will die as the disease runs its course.

Q: Looking at the rate of infection and that these people are going to die in their most productive years, what this is going to do to the economy of Uganda?

GRIBBIN: Quite clearly it’s already had an impact on Uganda. Due to AIDS Uganda lost the cream of the population in the flower of their economic productivity. Those folks had a higher rate of infection because they had money and were in the modern sector. In short, they were the most able to be promiscuous. The men had the wherewithal to buy beers and women. In rural areas, opportunities were fewer. Think of AIDS as a double whammy, not only do societies lose people in the flower of life, but they lose their best people.

“It was one of my greatest accomplishments — to force the issue and make it public”

Deputy Assistant Secretary for Sub-Saharan Africa Prudence Bushnell

BUSHNELL: We were paying a lot of attention to HIV/AIDS [in sub-Saharan Africa]. This was before the U.S. government recognized it for the catastrophe it is. Some of the dedicated scientists and health professionals made me a true believer and we become the first activists in the foreign policy community. George Moose was one of the first to understand the repercussions. With his backing we commissioned a National Intelligence Estimate, to include an unclassified conclusion about the impact of HIV/AIDS on African militaries and societies. It took me something like eight months to get them to publish their conclusions, even though it was unclassified. It was, in retrospect, one of my greatest accomplishments – to force the issue and make it public. It was the first time that anything had ever been done about the impact of HIV/AIDS.

Countries that had leaders who understood the impact of HIV/AIDS and made an effort to educate the public had far greater success in arresting it. Senegal is a case in point. They have kept the numbers down through committed efforts. In contrast Kenyan political, religious, and social leaders refused to acknowledge what was happening until the epidemic had spread to unacceptable levels.

I know that we were in the forefront. The United States was targeting resources to it. There was a certain amount of rhetoric given by other countries, but we were the ones who were most actively and strategically engaged. The international community, including the UN institutions, had not yet gotten their act together and there was a lot of talk about who had organizational responsibility. World Health Organization? UN Development Program? A new and specialized office? We have a much more concerted international effort now – and, far greater U.S. government resources being committed.

People were dying, in some countries at higher rates than others. Uganda had a huge rate of AIDS. So did Rwanda and later, South Africa. But we were not seeing the number of infected people, orphans and social impact that you do today.

[AIDS as a sexually transmitted disease] was a huge problem. Africans, like a lot of Americans, are very conservative and do not talk about these things. People willing to discuss how the disease is spread or prevented are getting into parts of people’s lives that are intimate. Also, you cannot talk about HIV and AIDS without getting into the issue of women’s empowerment – or lack thereof.
At that time we were pushing condoms. We were into commodities big time, promoting safe sex. We were also into education. In Central Africa, the most popular condom was called “Prudence.” You can imagine what a wonderful time people had with my name. When I left the African Bureau I had a drawer full of Prudence condoms, Prudence aprons, Prudence t-shirts. These were francophone countries and the tag line in the advertisements was “j’aime avec prudence.”

Oddly enough given some of the problems we were facing, there was a sense of optimism [in the Africa Bureau]. The mantra was “things are desperate but not hopeless.” Lots of gallows humor. There was a healthy esprit de corps and a management unit that really, really took care of people.

“In village after village there were no mature adults…Everybody in between was dead”

Deputy Chief of Mission Stevenson McIlvane

MCILVAINE: [The AIDS epidemic] was devastating. We first became aware of it in the Congo in ‘83-’84. At the embassy there, we had a guy named Jonathan Mann. He was doing the first serious AIDS research at Mama Yemo Hospital. I got to know him. His wife then was French and she worked with me as a translator. She was our local hire translator for documents and things like that. Mann later became the UN World AIDS guy.

We became aware of this horrible disease. People were dying. It was just beginning to appear on the national scene back home. We went to Tanzania and it was not noticeable in Dar es Salaam and amongst the people I worked with. But I was hearing about it upcountry particularly around the southern shores of Lake Victoria. This belt here from southern Uganda to northern Tanzania was just devastated by AIDS, village after village.

So I flew up to Bukoba, the Tanzanian town on Lake Victoria, just to find out what was going on. I went to the hospital there and came back horrified. It was a war zone. Right out of town there were villages… One had 223 orphans. Basically, people were telling me – these were Catholic priests and the medical workers at the hospital – that in village after village there were no mature adults. It was kids and the old folks. Everybody in between was dead. The old folks were struggling somehow to manage the kids and to feed them. I had a long talk with the folks at the hospital in Mwanza, where they were struggling to get surgical gloves because their health professionals were starting to die off. It was clear something serious was going on.

My next assignment was Zambia and there it was in plain sight. People I worked with at the foreign ministry just withered and died, disappeared. No one would say what had happened to them. “Where did So and So go?” “Oh, well, he died last week.” “What happened?” “Oh, something.” It was clear what it was.

About five days before Christmas, we had been there three months, and the cook’s teenage son knocks on the door about 4:00 AM and says, “Mama is very sick and we need your help.” So I go with him to the servants’ quarters and she is extremely sick. I carry her to my Land Rover, put her in the back seat of the Land Rover, and drive him and her to the hospital. Two days later, she’s dead. It’s AIDS. We had just gotten to know her. The kids were playing with her children. All the rest. So it got right home very quickly.

Then every day the procession of funerals going out to this graveyard that was on the way to the school… It was devastating. It was wrecking Zambia. And then you hear the stories later about Botswana, where it’s even worse. One of every four adult males is infected. It’s appalling.

One other thing on AIDS that particularly came through while I was in Zambia was the extent to which culture contributed to it. AIDS in Africa, or at least in the parts of Africa that I was dealing with, southern and eastern Africa, was transmitted mostly through heterosexual contact. That worked for several reasons.

One, the poor medical system. There was a lot of venereal disease which meant that there were open sores. It meant that if one or other of the partners was HIV positive, it was much easier to transmit the disease than it is in the West, where healthcare is reasonably good and you don’t have open sores. Secondly, the healthcare system was in very bad shape. Government after government had not put its resources into that. Healthcare was very limited.

Thirdly , how much the culture contributed to it. The view that the urban male could be a predator and that was just fine. My wife likes to say that the most dangerous thing a woman could do in Zambia was get married because you could count on your husband running around, becoming HIV positive, and then infecting you.

There were all these stories about how the woman was supposed to pack their husbands bag for a trip — not a very liberated society — and put in the condoms so that when he was playing around on the trip. That contributed enormously to the easy transmission and the movement of the disease and the devastating impact it had on usually the most educated, the most privileged section of society. It was a bad news story all the way around. There was no good news about it.

As DCM, part of my responsibility was the morale and the protection of the mission. We did spend some time keeping the mission educated on the disease and the situation and how it could be transmitted. Basically, although it was all around us, we were well insulated from it. The Zambians around us were not. Hardly anybody could escape noticing that. We didn’t have any AIDS within the American community. We had to consciously reassure our people that if normal practices were maintained, you could prevent transmission from servants or anybody working on your house or anything like that. So we didn’t have any panic. But it was always there, the cloud in the background. For some families, it came right into the foreground when somebody you knew or worked with or admired or respected withered up and died.