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Fear and Loathing HIV in South Africa

By Douglas Foster,
an associate professor at the Medill School of Journalism at Northwestern University.
Tuesday, June 3, 2008

SIZWE'S TEST

A Young Man's Journey Through Africa's AIDS Epidemic

By Jonny Steinberg

Simon & Schuster. 349 pp. $26

In the midst of an epidemic, surely you would want to know whether you carry the virus responsible for spreading the disease. Or would you? If the illness were lurking at the intersection of sex and death, perhaps you'd reconsider. If you risked ostracism from your family and community, maybe you'd think again.

"I cannot test," says the central character in "Sizwe's Test," a riveting look at the AIDS epidemic by South African journalist Jonny Steinberg. "How can I ever be ready to hear that I am HIV-positive? If I test today, and the result is positive, I will have to call off my marriage. . . . No woman could be my wife. I would be like an ox: I would sweat in the fields for a while and then get sick and die."

This is a dangerously melodramatic vision, but the image of a man turned into a castrated beast just by learning his HIV status hints at the turmoil that still swirls around diagnoses. Ever since the epidemic shifted course, moving from hard-hit communities of gay men and IV drug users in the First World to the generalized pandemic spread mostly through heterosexual contact in sub-Saharan Africa, few writers have gotten very deeply under the skin of this still-unfolding catastrophe. Steinberg's book is a significant contribution.

Encouraging people to test is at the heart of the worldwide campaign against the spread of HIV. If people don't know their status, they can't protect themselves from falling ill or shield their sexual partners from infection. For years, health advocates complained that political leaders failed to push a coherent program to test, counsel and treat with the kind of urgency that was needed. It's never been an abstract debate, especially in Africa: Two-thirds of the estimated 33.2 million people around the world who are HIV-positive live in sub-Saharan Africa, and 1.6 million died of AIDS in the region last year. Approximately 5.5 million South Africans (one in eight) are living with HIV, the largest number in any single country.

Among the biggest challenges for health workers has been that so many people, especially men, refuse to be tested. In areas where clinics have made testing easy and treatment accessible, men even turn away from medical help that could make HIV a treatable chronic condition. Those who do test, but test late, run terrible risks. Starting medication once you're seriously ill makes it much harder to recover and thrive.

"Sizwe's Test" unravels this mystery. The story orbits around two key characters -- Hermann Reuter, a white doctor for Médicins Sans Frontières (Doctors Without Borders), and a black shop owner called Sizwe Magadla (a pseudonym) who was initially skeptical of Reuter's motives.

The doctor's task was a difficult one: He moved into the Eastern Cape of South Africa in 2003, a time when the national government refused to provide anti-retroviral treatment in public clinics. To make matters worse, President Thabo Mbeki and his health minister raised public doubts about whether anti-retroviral medication was effective and safe.

The clinics Reuter served were notoriously understaffed and suffered from a litany of neglect. With the help of community health workers, nurses and activists from the treatment action campaign, Reuter launched a remarkably successful program of testing and treatment. He even began to win Sizwe over.

Sizwe, who was also Steinberg's chief interpreter and guide, helped explain the resistance Reuter faced. He led Steinberg through remote villages to help him understand what he called "black people's secrets." Some of these secrets sting. Sizwe reports that many people in his village believe that white doctors' needles are used to spread AIDS rather than to treat it. Many think, too, that HIV can enter the body through a kind of demonic possession as well as through sex -- and that a spiritual remedy, not just a medical one, is required. Sizwe himself admits to harboring the suspicion, quite common, he says, that white people know of a cure for AIDS but are keeping it to themselves.

Steinberg has a finely tuned ear for the way real people talk and think. In a few places there's too much of Sizwe's shifting moods and not enough about the women -- volunteer health promoters -- who have done much to bring universal access to treatment. But Sizwe's transformation from someone who initially viewed Reuter and his supporters as a kind of secular cult to someone who accompanies ill friends and relatives to clinics and urges them to get tested is compelling. Until the book's final pages, we don't know whether he's capable of taking his own advice. By then, all the easy assumptions about what we might do if we were unlucky enough to be in his shoes have dropped away.

Nearly 30 years after the AIDS epidemic began, this provocative account offers something genuine, important and new.

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