cc  >> Kate Siemieniewski:  Good afternoon and welcome  to today's Global Hot Spots  lecture.  My name is Kate Siemieniewski.  I'm the Program and Outreach  Assistant at the Wisconsin  Alumni Association.  WAA is pleased to continue our  partnership with the Division of  International Studies and PLATO  and Continuing Studies to bring  this outstanding program to you.  Today, we welcome professor  Claire Wendland as our speaker.  Claire is an assistant professor  in the Departments of  Anthropology, OBG,  Medical History and Bioethics.  She worked as a practicing  physician on the Navajo  Reservation before turning to  medical anthropology.  Her ongoing research focuses on  medical expertise in African  settings.  She has done field work in  Malawi over the course of  several years.  Through this work she attempts  to bridge theoretical and  material divides between  medicine and the humanities,  between lived experiences of the  body and knowledge about it. 

 Please join me in welcoming  professor Claire Wendland.  [APPLAUSE]  >> Claire Wendland: Thank you,  Kate.  Good afternoon.  Can you hear me all right?  >> No.  >> Yeah, it sounds really quiet  to me too.  Let's see.  Kate, any idea how we work  a volume?  Maybe it's here.  How's that?  Any different?  >> No.  >> I hate to put it too close.  Any better?  In the back can you hear me  all right?  >> Yeah. 

 >> Okay, good.  So I should be really clear  right up front with you that my  research is actually not on  HIV/AIDS in Africa.  I work on medical education, the  experience of doctors and nurses  and midwives who work in Africa.  And I also work, my new project  is on understanding really an  epidemic of maternal death, so  pregnancy related death,  in the country called Malawi.  But you can't work on either  of those topics without really  encountering issues with  HIV/AIDS every day.  In this talk I'm going to build  a lot on the work of other  researchers, very few of whom I  will actually credit here, and  some from my own experience.  So some of you might not know  where Malawi is.  That square red box encompasses  a little skinny country,  you might be able to see it's a  little bit brighter yellow than  the surrounding map, and there's  a big lake on the east side.  It's at the southern end of the  Rift Valley of Africa.  Many people know where it is  nowadays because Madonna is  establishing a school there and  has adopted two children from  Malawi. 

 So now when I go to Malawi, I  get asked if I'm going to come  back with children.  And the answer is no.  [LAUGHTER]  I first went to Malawi in 1990  when I was a medical student  myself.  I've been back several times.  I spent a year there in 2002 and  2003.  Most recently spent the first  half of 2007 there.  It's one of the poorest  countries in a very poor region  of the world.  And that has everything to do  with the HIV epidemic there.  So I want to start, I'd like to  kind of ground what's going on  with HIV in southern Africa  through a story of a real  person.  So I'm going to tell you this  story of somebody that I knew in  Malawi and I'm changing her name  but otherwise the story is true. 

 Ten years before I met her, Mary  Phiri moved to the city from her  mother's small farm at age 15.  She was elegant, she was  educated, she had finished  junior high, and that alone set  her apart from 90% of other  Malawian girls.  She spoke fairly good English,  and she was able to find a job  as a shop girl.  As the years passed, her friends  and family noticed that she was  starting to get pretty thin.  Nobody said anything except to  ask if she was getting enough to  eat.  One day at work, she fell.  Her legs collapsed under her.  Another shop girl brought her to  the city's big public hospital  which is called Queen's  Hospital, Queen Elizabeth  Central Hospital.  Her workmate left her in the  line waiting to be seen at the  out-patient department and  walked on the way back to her  job to let her sister, Mary's  sister Loveness, who also had a  job in the city, know what was  going on.  When Loveness got to the  hospital hours after work, she  asked around and she was able to  find Mary who was by then in the  women's medical ward. 

 Mary could hardly move her legs  and had tremendous back pain.  She told Loveness she didn't  know what was problem was, but  the clinical officer had said  that she would need an x-ray and  that she would have to stay for  at least two weeks.  Loveness sent a message to their  mother.  To do this, by the way,  she couldn't just call.  She called a Catholic mission  somewhat near their home.  The nun there who took the phone  message, gave the message to a  school girl.  A school girl took a half an  hour walk to the family's home.  At that point, Loveness and  Mary's mother took her small  savings, sold two goats to cover  extra expenses, put the farm in  charge of the youngest child who  was still at home and left for  the city.  By the time Mary and Loveness'  mother arrived, Mary had had an  x-ray of her spine and was told  she had spinal tuberculosis.  She had no HIV test. 

 The hospital was out of the  equipment needed for tests,  there was no money to buy more  and no one recommended it even  though most cases of spinal TB  in Africa are HIV related.  Mary stayed in the hospital,  her mother cooking her meals and  trying to tempt her with the  food, and washing her cloth  covering outside in the  courtyard.  Then sleeping under her metal  cot in the hours that guardians,  as they're called, are allowed  in the hospital.  A month passed  and then six weeks.  Mary seemed worse.  She had developed a bed sore  where her right hip pressed into  the interlaced wires that served  as a mattress.  The sore was covered by a piece  of gauze that got changed every  few days, but it did seem to be  worsening.  Mary had a great deal of pain  but there was only Tylenol to  treat it with.  The hospital had no narcotics.  Perhaps worse, Mary's mother was  almost out of money and almost  out of time to plant for the  next harvest, the food that  would sustain the whole family. 

 And no one could tell them what  to do.  At this point, the sister,  Loveness, who was and  acquaintance of mine, contacted  me.  Now, I had worked at this  hospital but in a happier unit,  mostly happier, in the  obstetrics unit.  And that's me in the weird  looking hat on the right.  You probably guessed which one  was me, didn't you?  [LAUGHTER]  So this was the country's  largest referral hospital.  This is a country, by the way,  of about 12 million people.  It's one of three  central hospitals.  And in terms of numbers of  patients admitted at any one  time, it's about four times the  size of all of UW Hospitals and  Clinics.  So it's big.  Despite its size, it's woefully  undersupplied and understaffed. 

 One nurse takes care of 60 to 80  patients on any given ward.  This is the special care newborn  nursery.  That will give you something of  an idea of the conditions.  In 2003 when I was there, the  power was on about half the  time, the water was on most of  the time, but we had no soap.  When I was back in the first  half of 2007, we had much better  water and electricity, which is  great, still problems with soap,  and for two weeks the entire  country ran out of sutures  so people actually died because  they couldn't have necessary  surgery.  And in the central hospital we  were sterilizing fishing line  and people were digging expired  suture out of their offices  where they had saved it to try  to teach the medical students  how to tie knots.  On the labor ward, an estimated  30% to 40% of women are HIV  positive.  On the medical and surgical  wards, it's 80% to 90%.  When I went to see Mary it was  my first time on the women's  medical ward.  A hundred patients were packed  into a space meant for 38,  plus their families. 

 When I walked in, three faith  healings were going on  simultaneously, prophets calling  down the name of Jesus on the  very sick and skeletal people  lying in the beds.  They looked like they needed  miracles and so did Mary.  She weighed 77 pounds.  She was down 20 pounds since her  hospital admission.  She wouldn't speak or make eye  contact.  When I peeled the dressing away,  she didn't flinch but I could  see her wound, her bed sore,  was down to the bone.  I spoke to the nurse and the  clinical officer, and the  clinical officer is sort of like  a PA.  There aren't all that many  doctors in Malawi yet, and so  these midlevel providers called  clinical officers do a lot of  the day-to-day work, including  surgeries, that doctors would do  elsewhere.  So I talked to the nurse and the  clinical officer.  They had continued giving  medications for TB because they  didn't know what else to do. 

 There was a small chance that  she could get better if she was  taken to surgery to clean up  both her bed sore and actually  to drain her spine of the TB.  But the line of patients waiting  was very long, and she wasn't  even close to the top of it.  There weren't enough surgeons or  operating room nurses.  So I got her transferred to the  orthopedics ward which was a  little bit less hellish, and I  tried working my connections to  get her into, bump her up the  line into surgery but I failed.  And I talked to Loveness and her  mother about HIV to see if they  would talk to Mary about getting  tested.  They didn't see the point.  How could Mary have HIV,  she wasn't even married.  It didn't matter because there  were still no tests, and if she  had been positive on a test  that we didn't have, there was,  at that point, nothing  to be done about it anyway.  So I brought in clean dressings  to change every day, change her  wound every day, but over the  next five days the sore got  worse and it was now eating into  the bone itself.  Finally the family had had it,  and they decided it was time to  take her home. 

 They didn't have a car  and neither did I.  And Mary, at this point,  couldn't uncurl herself enough  to squash herself onto  the public transport minibuses.  So I, again, sort of worked the  expatriate connections to get an  illegal loan of an ambulance,  an old vehicle, it's called an  ambulance but it's really a Land  Rover, from a malaria research  project that was run  by an American University.  And we took her home.  It was a four hour drive  over bumpy dirt roads.  It must have really hurt  whenever we hit the bumps,  but she only cried out once or  twice.  At her house, a dozen family  members carried her gently in  and settled her on the floor.  And we left her with more  Tylenol and a bottle of expired  Codeine brought illegally from  the US in case of dental  emergencies.  She died about two weeks later,  and her mother cared for her  until the end.  Mary Phiri never made it  onto any registry of deaths. 

 Formal death certificates aren't  required or widely used, and  because she died outside the  hospital, her death isn't marked  on any official piece of paper  at all.  But if we had to determine her  cause of death, what did she die  of?  She was very skinny, even going  into the hospital, was this  malnutrition?  It looked like she had  tuberculosis, both clinically  and on the x-ray, but the other  tests were never done, as far as  we can tell, and the diagnosis  is difficult to make.  Was it AIDS?  Her story is really suspicious,  and I assume she was HIV  positive and suffering from the  effects of it.  But in fact she never had an HIV  test because there weren't any.  Is it reasonable to think that  she died of poverty?  Her family was not one of  Malawi's poorest families.  They were considered  middle-class.  It's true they had no plumbing,  no electricity, no telephone,  but they had a small farm, good  land, goats, their hut, unlike  these, had an iron roof instead  of thatch which considered a  marker of the middle class,  and there were two employed  children.  Still, they were poor enough  that by age 15 all the children  were told they had to fend for  themselves, which is not  uncommon.  It took Mary a long time to go  to the hospital.  She was afraid of the costs of  hospitalization, and she was  afraid she would lose her job if  she was away from it for too  long. 

 As, in fact, she did.  And then when she got there, she  got terrible care, frankly.  And this, too, is a result  of poverty.  Not hers or her family's  so much as her nation's.  There were no proper  medications.  There were inadequate wound  dressings.  There were not enough nurses and  surgeons to get her to surgery.  There were not enough tests to  be sure what was wrong.  There were no antiretroviral  medications to treat HIV at that  time even though they had been  available in the US at that  point for 18 years.  They were too expensive still  for Malawi. 

 So I guess arguing that it  doesn't make sense to attribute  her death only to any one of  these factors and that the  problem the HIV/AIDS has to be  put into the context of other  problems affecting Africa and  Africans.  And that putting it into that  context reveals connections that  we might not suspect but also  maybe gives us some ideas for  solutions that we might not have  guessed at either.  Okay, now the depressing  drill of numbers.  Sub-Saharan Africa has  two-thirds of the world's total  cases of HIV, including all the  countries with the highest  infection rates in the world.  AIDS in Africa has been likened  by some people to the perfect  storm.  Southern Africa seems to be  the epicenter hardest hit.  2008 data, you can see it,  34 million people,  two and a half million  AIDS deaths every year.  Malawi isn't the worst or the  best of the countries involved.  And Africa, in general, it's  estimated that about one in 20  adults are infected with the HIV  virus.  And that compares, just for your  information, to about one in 200  in the US. 

 In Malawi, in the general adult  population, so not just in  hospitalized people, it's about  one in seven.  And it's closer to one in three  in the big cities.  Like other countries in southern  Africa, in Malawi HIV affects  more women than men and affects  them at substantially younger  ages.  And we'll talk about that soon.  So for the rest our time I want  to look at some of the  historical roots of the HIV  epidemic, examine some responses  very briefly, and think even  more briefly about what happens  next.  So putting the epidemic into  historical context, we have,  I think, four major factors.  The cash economy, limitations of  government response, issues in  gender relations and stigma.  Now other researchers would  probably pick out other themes.  I think probably everyone would  agree on the first and the  third, probably.  But I'm going to go with these  four. 

 So the cash economy.  As far back as oral history  records, women in most of Africa  were the primary farmers and the  primary marketers.  So they actually had  considerable economic power.  Colonialism shifted this power  because all colonial powers  introduced a cash economy.  Why did they do that?  Well, Malawi didn't have that  much that the colonizers, in  their case Britain, wanted, but  it did have rich agricultural  land and a lot of people who  could potentially work that  land.  It didn't have gold or diamonds  or copper or some of the things  that some of the neighbors had.  Land, some of it simply got  confiscated, other land was  obtained by treaties with  powerful local leaders.  Labor was a thornier problem.  There were many Africans who  could do the work for the  colonizers but they didn't want  to.  And the introduction of cash  taxes was a way around this  problem. 

 Taxes were to finance the  colonial bureaucracy.  The colonies were expected to be  financially independent to pay  for themselves including the  salaries of officials who came  from Britain and the cost of  building roads and other  infrastructure.  But the more important function  was to mobilize African workers.  Every household had to pay a  certain amount each year in  cash.  Now this wasn't a cash economy,  initially.  How were you going to get the  cash to pay the taxes so that  you wouldn't be punished?  Well, the only way was to work  for a European on a plantation,  in a mine in a nearby country,  some place where somebody who  had cash could pay you.  The British knew that women were  the primary farm workers and  mistakenly thought that men  weren't doing any work so this  wouldn't affect the social  system.  This began a long history of  male labor migration for  employment which by now has  become an entrenched response to  problems of poverty.  Employment had some direct  effects on health.  There were lots of occupational  diseases and injuries related to  heavy workload and unsafe  working conditions. 

 Nutrition at the workplace was  typically fairly poor.  And there were diseases that  spread quickly in crowded  conditions.  So this is a South African  miners dormitory, and each of  these little cubicles is one  guy's space to live.  So you can see their stuff is  all tucked up on top.  So you can imagine, if one  person gets TB in here and  starts coughing, it spreads  between all the men pretty  quickly.  So there's some direct effects.  But there were indirect effects  at home, too.  The absence of male labor in the  fields meant that hunger spread  pretty quickly.  In addition, there was a  breakdown of social structures.  These guys were often away from  home for years at a time. 

 There's an increase in sexually  transmitted diseases that they  brought home when they came  home.  In the early years that was  mostly gonorrhea, chlamydia,  but in more recent years the  deadliness of the infection has  increased.  And by some estimates, there's  no great estimates, but by some  estimates, half of South  Africa's migrant mine workers,  many of who were Malawians,  infected their wives with HIV on  their return.  One researcher, Catherine  Campbell, has argued that this  isn't all about women's  vulnerability, that some of it  is about men's vulnerability,  too.  And based on her work with South  African mine workers, she argues  that in the face of a job that  they perceive as running the  risk of death at any second,  they begin to construct their  own ideas of what it means to be  a man, as a man takes risks.  And you can imagine what some of  the consequences of that might  be for sexual practices.  That risky sex is also part of  masculinity, as well as one of  the few pleasures available to  them in life.  So the cash economy was  difficult, very difficult, for  migrant men but it also  marginalized women.  Cash jobs were for men, at least  initially, and still most of  them are.  The increasing importance of  cash just to get along meant  that women devoted more and more  of their agricultural efforts to  crops that they could sell,  tobacco, cotton, etc, instead of  crops that they could eat. 

 And so the margin of safety,  nutritional safety for any given  family was really thin.  Especially in the dangerous  months, February or March before  harvest which are known to this  day as the hungry months in  Malawi.  At the same time women were also  marginalized legally by new  colonial laws which were modeled  after what was then current in  Europe and so thought to be the  best available that made it  harder for them to divorce  unsatisfactory husbands or to  inherit property.  So women were made more  vulnerable, both to malnutrition  and to sexually transmitted  infections, as the cash economy  became powerful in southern  Africa.  Well, couldn't medical care sort  of help cure some of these STDs?  Not so much.  During the colonial era, there  wasn't much medical care for  Malawians, for the great  majority.  There was some scattered mission  hospital care, but it was very  scattered, geographically, and  it was never completely free.  In the earliest days of the  colonies, government medical  care was only for white  settlers.  Later there was some healthcare  for plantation and mine workers,  and government care for all  people actually only began as  colonialism was coming to an  end.  So only in the sort of late  1950s. 

 And it was very thin on the  ground.  After independence in the 1960s,  new governments, including  Malawi's, expanded access to  healthcare.  But the government's capacity to  respond was limited by both  internal and external factors.  I can answer some questions  about this after if you want,  but let me just say internally  the country was really poor so  there wasn't a lot of money to  devote to building hospitals and  training nurses, but also the  first post-independence ruler  rapidly became a dictator and  spent a lot of money building  monuments to his own glory  rather than education and health  systems.  External factors were important,  too.  The newly independent countries  inherited the debt that the  colonies had incurred in their  name and quickly incurred their  own debts, too.  And beginning in the 1980s, just  as the AIDS epidemic was  beginning, new policies for this  debt, new policies about loans,  reshaped the government's  capacity to respond to the  epidemic.  Loans from the World Bank and  the IMF have never been without  conditions, they're not supposed  to be, but as these loans became  increasingly large components of  the budget, these conditions  actually came to dictate a lot  of state policy.  And in the 1980s in an era of  economic crisis in much of the  southern hemisphere, the major  lenders set new conditions for  the loans based on principles  outlined in a new report.  And these conditions have come  to be called structural  adjustment. 

 Co-pays for health and education  were required.  State services were to be sold  off to the private sector  wherever possible.  State worker salaries were to be  frozen and no new state workers  were to be hired.  Currency was devalued.  The economists among you will  understand what that means.  Frankly, I barely understand it,  but in fact what happened was  triple digit inflation, in most  cases including Malawi's, in the  next few years.  Meantime, minimum wages were to  be frozen or eliminated, as were  price controls, food subsidies,  fertilizer seed subsidies, and  labor protections.  Now, these conditions didn't  only apply to loans, they had to  be state economic policy for the  entire state budget before any  loans would be approved.  And in fact, even before the  loans that had already been  negotiated were delivered.  It's not illogical, completely. 

 Here's the economic logic.  The idea is if you require  co-pays, you sell government  services, you abolish price  controls, you're directly  reducing the government's  expenses.  You're cutting the government's  budget.  And it's assumed to bring the  efficiency of the market into  inefficient government  bureaucracies.  But, of course, that means that  the assumption is that  bolstering the economy is the  prime function of a government  rather than feeding, educating  or providing healthcare for its  people.  With less labor protections and  a lowered minimum wage, you  should get expanded production  because businesses will invest  where they find cheap labor.  But that also means poor people  have to work harder in more  dangerous conditions to make  anything resembling a living  wage.  Currency devaluation reduces  in-country demand, so more is  available for export.  And that increased production  and decreased consumption  benefit the balance of trade.  So without price controls or  currency regulation, these  frozen wages enable workers to  buy less and less even as they  have to produce more and more to  keep their jobs. 

 So the amount of resources  extracted from the country and  sent abroad can increase.  So maybe it's not surprising  that since 1988 when these  programs came to their height,  the net flow of wealth, even  when we include all foreign aid  and donations, has gone from the  poorest to the wealthiest  countries of the world.  All right, well at this point  many people are asking  themselves why didn't these  countries just say no to these  loans.  Some places actually did that,  and we can talk about that later  if you want, but others didn't  feel able to.  In Malawi, for instance, six out  of every seven dollars spent in  the health system and three out  of every four dollars in the  education system comes from  these loans, loans in donor aid.  So to refuse them would be to,  basically, make these systems  collapse.  This, by the way, is really  close to where I live in Malawi.  In my favorite part.  This is the public transport  system.  Seriously. 

 And my favorite part of this  slide is the eight-year-old  mechanic here working in the  front.    So these policies have been  modified slightly but not much  in recent years.  But just at the time they were  at their height was the 1980s  and '90s when you had this  explosion of HIV on the  continent.  So some of the factors involved  were people's day-to-day  survival was threatened, feared  long-term thinking about health  may be lessened.  Transactional sex became a key  to socioeconomic survival for  women and an important emotional  prop for men and women alike.  What do I mean by transactional  sex?  This is just sex in exchange for  something, for something  material.  So in the US after a couple has  been dating for a certain amount  of time and somebody buys  somebody else a really, really  fancy dinner out and a show  etc., it's sort of expected,  maybe, that sex will happen.  Right?  I assume you know this.  [LAUGHTER]  The undergrads do.  [LAUGHTER]  So that's transactional sex. 

 But in Malawi it's more commonly  an exchange for school fees or a  place to live, or maybe support  for your child.  It isn't the same as  prostitution or commercial sex.  And many people who support  themselves to large extent  through transactional sex would  be horrified to be called  commercial sex workers or  prostitutes.  And it's very often part of  relationships that include  substantial emotional attachment  or affection and infection.  Just as it is in the US.  But when transactional sex  increases, especially among very  mobile people who may be going  place to place to seek work,  it's still a risk for HIV and  other sexually transmitted  infections.  This raises some questions for  me.  How did Mary find her job in the  first place?  Who did she stay with when she  first got to the city before she  had a job at all?  How did she survive earning  minimum wage of 57 cents a day,  a wage that stayed flat even as  prices rose and rose.  These tea workers earn a little  bit under a dollar a day, and  that's considered a good job  because it's actually higher  than the minimum wage.  Mary's mother and sisters didn't  know the answers to these  questions. 

 But it wouldn't be surprising if  she, who was, after all, an  educated a beautiful 15-year-old  girl completely alone in the  city in 1992, had little choice  but to accept the offer of a  relationship from a much older  man in exchange for a lead on a  job or a safe place to stay.  These kind of so-called sugar  daddy connections that you may  have heard of probably explain  the particularly  disproportionate HIV infection  rates in young women.  So among women 15 to 24, excuse  me, among people 15 to 24 years  old in many countries including  Malawi, girls who are HIV  positive outnumber boys by a  four to one ratio.  Another factor that played a  role was the crumbling of the  public health sector.  So you remember employment in  the public health sector had  been scaled back pretty sharply  and wages frozen, even at a  moment that a devastating  epidemic was hitting the  country.  Budgets for medications and  supplies were also frozen.  So you have these deteriorating  public hospitals packed with  gravely ill patients who are not  going to get better.  And I can't tell you how much  AIDS added a huge draw on  resources, human resources,  material resources, beds,  nurses, lab tests that were  already seriously strained under  budget constraints.  The change in the health sector  affected HIV by a couple of  mechanisms.  First of all, the availability  of healthcare was limited by  this scale down of public  services. 

 What that means is if there's  less healthcare, it's harder to  get other sexually transmitted  diseases treated.  So if you have another diseases,  and actually some of them aren't  sexually transmitted either,  but say syphilis, or gonorrhea,  or Schistosomiasis, which is a  parasitic infection that causes  ulcers around the genital area,  it dramatically increases your  risk of getting HIV from any  individual incidence of unsafe  sex.  So limited healthcare also made  sure expensive medications used  to treat AIDS, and in many cases  like Mary's even the test needed  to diagnose it, were just plain  unavailable.  But I think it's probably not  all about limited healthcare,  it's probably about unsafe  healthcare too.  And this is an area that has  really been under investigated.  Inside health facilities there  were a lot of unsafe medical  practices.  We know, for instance, that five  needles were used to inject 400  patients a day at a mission  hospital in, what was then,  Zaire in the mid-1980s.  How do we know that?  Because an Ebola epidemic that  happened in that hospital was  traced back to those needles.  We know that in 1990,  one scissors was used to cut  umbilical cords at this delivery  ward in Queen's with 14,000  births a year.  How do we know that?  Because I was a medical student  who was there, and I was taking  the scissors and running back to  a pan of disinfectant, switching  the scissors around and running  to the next birth to cut the  cord. 

 Fortunately, HIV is not a very  efficient virus with  transmission, we probably didn't  transmit a lot of HIV that way  but we probably transmitted  some.  Might Mary have contracted the  HIV from an IV when she went to  get treatment for a bad bout of  malaria?  It's possible.  So you can see how all of this,  I think, the cash economy,  gender relations, which I  haven't addressed much but a  little, economic policy, adds up  to a perfect storm.  But the perfect storm isn't only  for HIV.  I can give, and in fact I have  given, a very similar talk about  why maternal death rates are  rising in Malawi to this day.  You can do a similar analysis  of problems with tuberculosis,  to some extent even malaria.  So how do people respond to this  terrible epidemic?  Well actually social responses  to many epidemics follow a  predictable pattern.  And this is something that  anthropologists and historians  have noted for a long time.  It starts with denial.  In the Malawi case, well AIDS  doesn't really exist, these  illnesses are really caused by  witchcraft and AIDS is a new  cover for witches to hide their  activities. 

 That's pretty closely followed  by resentment towards those who  brought the bad news.  So in 1990 when I was first in  Malawi there was a this sort of  bitter joke that AIDS stood for  American Ideas of Discouraging  Sex.  [LAUGHTER]  This is Americans  trying to tell us not to have  sex because they're terrified of  African population growth.  But then there's the gradual  acceptance of the epidemic as  reality, and that tends to be  accompanied by a use of an  epidemic as opportunity to  reaffirm the social values of  the majority, usually by blaming  the victims.  So this epidemic is God's  punishment to individuals or the  whole community.  This epidemic is because we've  fallen away from healthy  traditions of monogamous  marriage.  So, hence, a lot of blame  leveled at men who have sex with  men in the US about this.  Or in Malawi this is about  uppity women and young people  deserting the ways of the  ancestors.  So again kind of reaffirming the  values of the majority by  scapegoating, people who can be  put out there as some sort  of contaminated other.  So this kind of victim blaming  actually makes the stigma of the  disease pretty great, and a  desire to deny that it's even  possible in your family, perhaps  greater yet. 

 So maybe we can understand why  Loveness and her mother were not  particularly interested in Mary  getting an HIV test.  All right, so what comes next?  There's actually a lot of  controversy about what the  economic and demographic impacts  of this epidemic will be.  So I'm not actually really going  to discuss that particularly.  I don't find the research  conclusive.  But it's probably going to be a  pretty substantial impact.  By some estimates in South  Africa, the country of South  Africa, in five years a quarter  of the adults alive now  will have died of AIDS.  Each victim will have cost his  or her family a significant sum  through healing of all sorts,  from herbal, to faith healing,  to hospital care.  When the victim was also a  breadwinner, which is about two  out of five in South Africa  but fewer where unemployment is  worse like Malawi, or where the  victim is the primary  agriculturalist, the cost  escalates.  A so-called decent funeral  typically costs about a year's  income.  Almost all of the victims,  because they tend to be young or  middle-aged adults,  will leave behind children. 

 These children get absorbed into  wider family networks, but these  are really feeling the strain.  In Malawi, every family I knew  had taken in at least one orphan  child.  Many of the medical students  that I knew were paying school  fees for their nieces or nephews  out of their own loan money.  So foregoing books, just using  the library when they could  at the hours that it was open  to help, particularly, their  younger sisters or their nieces  avoid these sugar daddy  relationships.  How to address this problem?  A lot of ideas about this,  actually.  Political leadership is clearly  crucial.  The most responsible political  leaders acknowledge reality and  take a lead in tackling it,  and provide hope.  But you also have to be aware  that political leadership  involves being prepared for the  growth of alternative religious  and political movements that  promise to cure AIDS, so various  sorts of healings, or place the  blame elsewhere.  Part of what we're seeing,  I think, with the very virulent  anti-gay response that's going  on in much of Africa right now.  So political leadership  is one important thing. 

 Drugs.  This is a place where I can  actually give you some really  good news.  Relentless activism has had an  effect.  The days are, I think, over in  which officials could stall  by saying, those Africans  don't even have watches,  how will they know when  to take their medications.  By estimates, and I have to  admit I think these estimates  are high, but let's be  optimistic, by some estimates a  third of those needing treatment  are now on it in southern  African.  That compares to under 2%  only five years ago.  So that's a huge change.  Many countries, including  Malawi, are fairly rapidly  scaling up programs to get  antiretrovirals to as many  people as they can.  There are several sort of side  effects of these programs that  I think are worth considering.  Of course treating people who  are ill, that's a good thing,  but also it reduces stigma and  secrecy. 

 There are even some openly  positive healthcare,  HIV positive healthcare workers,  although this is still rare,  and it's definitely increasing  testing.  So when I was talking to trainee  doctors in 2003, most of them  opposed HIV testing at all.  They said how can you tell  somebody to take an HIV test,  that's giving them a death  sentence.  They had all changed their minds  by the time antiretrovirals were  more widely available in 2007,  and most of them knew their own  status.  Unanswered questions.  What sort of human and financial  resources are required to make  these programs sustainable?  What happens when more expensive  second line treatments are  needed?  What happens when treatment  access is overtly inequitable?  Finally, besides political  leadership and drugs,  I think we should be creative.  The problem is much broader than  a virus.  So the solution should be, too.  I don't really think we're going  to go back to a day when there's  no cash economy.  That's probably not going to  happen. 

 But perhaps rather than  preaching to young women about  staying a virgin, we could  provide cash employment  opportunities for young women.  Or figure out ways to bring them  up to parity with young men  in terms of wages.  Or what about increasing the  minimum wage so people could  actually have a living wage.  Or what about building safe  youth hostels for economic  migrants to the city.  All of these things may be worth  a try and see how they work.  What if men's jobs were less  dangerous or closer to home?  Would risky sex decrease?  What about changing  international economic policies  to increase state involvement  in health and education,  rather then decreasing it.  Basically, I think on all of  these fronts, we need better  data and very close analysis of  interventions that do and don't  work to tackle this epidemic.  And I'm going to end there,  and I would enjoy  taking your questions.  (applause)