Hopkins doctors look for clues to AIDS in Africa

THE BALTIMORE SUN

BLANTYRE, Malawi -- Dr. Taha E. Taha and Billy Chisupe are both trying to do something about the spread of AIDS in this small southern African country. One is a scientist from Johns Hopkins, the other a rural farmer with a dream.

Dr. Taha spends hours at his computer terminal in this, Malawi's biggest city, working over the statistics that chronicle the spread of AIDS from mothers to their children.

Mr. Chisupe, who lives in a small settlement less than 100 miles to the north, chops bark off a tree and soaks it in water to make an elixir, following the instructions he says he received in a dream last August.

Work by Dr. Taha and others throughout Africa has brought into focus the nature of the continent's AIDS epidemic. But the picture is of such bleakness that it drives thousands to seek out people like Mr. Chisupe.

Scientists from the Johns Hopkins School of Hygiene and Public Health have been in Malawi for a decade, full time for the past six years on a project funded by the National Institutes of Health.

When epidemiologists spread out over Africa in the mid- to late 1980s, they were doing the groundwork for what was expected to be trials of potential AIDS vaccines. When no vaccines materialized, the emphasis shifted to finding other ways of stopping the disease. The Hopkins Malawi project concentrated on mother- child transmission.

Dr. Taha, a native of Sudan who received his doctorate from Hopkins in 1991 and has been in Malawi for two years, now records an AIDS infection rate of 30 percent among the thousands of pre-natal patients at Blantyre's major hospital who are in the Hopkins study. That means about 10 percent of all babies born in the city will develop acquired immune deficiency syndrome.

It is a figure echoed in cities across this region of Africa. Urban women of childbearing age are thought to have the highest rate of infection, so, while an exact extrapolation is impossible, it probably means an overall infection rate of 10 to 15 percent in these countries.

Though there is evidence that the AIDS educational effort is paying off, the devastating impact of the disease on all levels of these societies is irreversible for the immediate future.

"Two people came to me in a dream," Mr. Chisupe, 70, said of his inspiration for getting into the AIDS business. "They were people long dead. They asked me if I knew of this disease that has no medicine. I said that I did."

Sitting in a small one-room structure with dirt walls and a thatched roof where he consults with those seeking his advice, Mr. Chisupe told of how these two men took him into the bush, showed him a tree and chopped bark from it.

They took the bark back to his house, soaked it in water in a bowl, poured the colored liquid into a cup and said to drink it. When Mr. Chisupe awoke, the bowl and cup were empty. He found the tree in the bush and it was untouched.

That night, Mr. Chisupe said, the men came back in a dream and told him that the drink would cure those with AIDS and prevent others from getting it. But people had to come to him to get their drink. And he was not to charge them, though he could accept money they offered.

The news of Mr. Chisupe's dream spread, first by word of mouth, then through the news media. Thousands came, crowding his house, breaking its windows.

The road to his home was re-graded. Pit toilets were dug. Malawian Red Cross tents were erected to house those who waited days for their drink. As with pilgrimage stops at churches with valued relics in the Middle Ages, a small village sprang up to sell items to the throngs.

The flood of people that engulfed Mr. Chisupe has receded in the past few weeks, but on a recent day a steady stream still LTC came -- all with plastic cups in hand, taking their drink of the brown liquid. Some left money behind; others just left.

"These people are desperate," said Dr. Taha. "I understand why they go there."

Dr. Taha thought that a study just concluded would give some hope to this country and others like it. Working from data that showed the first twin born to an HIV-positive mother was much more likely to contract the virus than the second, the Hopkins team studied the effects of cleansing the birth canal just before delivery.

Unfortunately, preliminary results show that the cleansing had little, if any, effect on transmission.

Dr. Taha said another study now being prepared will give pregnant women vitamin A supplements, since it is known that mothers with low levels of vitamin A are more likely to transmit the human immunodeficiency virus to their babies. Vitamin A is inexpensive, so the intervention could be used almost anywhere.

Malawi officials asked that Hopkins do some of the laboratory work locally to aid in the training of health technicians.

Several Malawians also have been given fellowships to the Hygiene and Public Health School.

"The Hopkins study has given us valuable data," said Dr. George Liomba, who directs Malawi's AIDS control program. "Though we are disappointed that the cleansing project did not yield results, we do know the rates of infection in Blantyre. It lets us know what we are dealing with."

The data gathered by Hopkins and others are beginning to explain why AIDS is basically a heterosexual epidemic in Africa and not concentrated among gay men and intravenous drug users as it initially was in the United States and Europe.

Some of the reasons are related to the mixture of traditional African customs with European social norms. Many cultures here are polygamous. A large number of wives is often considered a sign of status.

When men moved from their villages to cities, and from subsistence farming to a cash-based economy, that tradition translated into promiscuity as many men who could afford it had many sexual partners.

This explains why AIDS in Africa is a disease of the relatively well-off, killing members of the managerial class, those the continent can least afford to lose. This gives AIDS an economic impact beyond the devastating effect the epidemic has on health care budgets.

In neighboring Zambia, the effect on the country's middle class is evident in the Parliament. Elected in 1991, it has recorded 16 deaths among its 150 members.

"I would say at least 10 of those were from AIDS," said Guy Scott, a member.

Furthering AIDS' heterosexual spread is the fact that so many Africans have other sexually transmitted diseases that have gone untreated, often leaving them with genital sores and ulcers that facilitate transmission of the virus.

Another Hopkins team is in Uganda treating such diseases to see what effect that will have on the AIDS figures.

There are many other factors. In Malawi, traditional healers often apply medicine by making an incision with a razor blade and then rubbing in the medicinal mixture. A dirty razor blade is just like a dirty needle to the AIDS virus.

"Now, we tell people they should bring their own razor blade to the healer," said Margaret Mhlanga, a nurse in the Hopkins Malawi program who spent a month training in Baltimore. "And we tell traditional healers that they should mix up a separate batch of medicine for each patient."

Another widespread practice in Zambia that is not unknown in Malawi, called cleansing, requires the wife or husband of a deceased spouse to have sex with a member of the spouse's family. This is considered necessary to rid the survivor of the deceased's spirit. But with so many of the deaths caused by AIDS, and with the partner often infected, the custom contributes to the spread of the disease.

"We work with the traditional healers and the village headmen," Dr. Liomba said. "We recognize that they are the guardians of our culture and that they should be respected and not condemned. But we tell them that some of their practices have to be redefined in the context of the HIV epidemic."

Dr. Chipangwi pointed out that some traditional practices that might have helped stem the epidemic became distorted in the colonial era.

"It used to be everyone, at puberty, was sent into the bush for initiation rites during which the elders taught them about sex," he said. "The coming of Christianity put an end to that. As a result, we have a generation that never received such training and do not know how to talk to their children about sex."

Dr. Chipangwi also said that it used to be taboo for a woman to have sex for up to a year after childbirth. Death or dread disease were said to be the punishment for a violation.

"Modern science showed that was not true, but it was a natural way of spacing children that was lost," he said.

There are other forms of Western influence that might be contributing to the problem. Malawi's health officials say that their attempts to promote use of condoms are often thwarted by Roman Catholic teachings against birth control. About 20 percent of Malawi's 10 million people are Catholic.

In Zambia, a large and growing fundamentalist movement is also said to impede the condom message, preaching that faithful monogamy is the only way to avoid the disease and that condoms promote promiscuity.

Many churches hold that faith healing has been successful with AIDS, the same claim Mr. Chisupe makes for his bark concoction.

"It does not bother us that people with AIDS go to him hoping for a cure," Dr. Liomba said of Mr. Chisupe. "That does no real harm. But it is bad that people think it works like a vaccine because then they will not take other precautions."

Mr. Chisupe scoffs at the government's skepticism. "If it does not work, why have there been so many people here?" he asked.

"I have had people from Germany, from England, from America. Why would they come if it does not work? And many people from the government have taken the drink."

Dr. Liomba acknowledges this is true: "Even people from my own office have asked for transport to him."

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