Mr. Akokoro has the disease Ugandans call "slims." He has had fever and diarrhea for the past six months. His cheeks are sunken; his ears appear too big for his head. Every few weeks, a seamstress alters his pants to keep them from falling off his bony hips. When Akokoro speaks, a whitish, foamy spittle, from a fungal infection in his mouth, drools down his chin.
"I think I am a skeleton. It is very hard for people to recognize me . . . I am afraid because there is no medicine. I am waiting for death," said Akokoro, in an examination room in Mulago Hospital here. His doctor says he probably will die in three to 12 months.
Akokoro, 43, a Ugandan businessman who was educated in France, says he probably contracted "slims" by having sex with "about 100 women a year" for many years in Uganda, as well as in neighboring Kenya and Rwanda. He says he has never had a homosexual encounter or received a blood transfusion. Asked what kinds of women he had sex with, Akokoro said, "All."
Slims is AIDS, and Mr. Akokoro (a pseudonym that the patient chose for himself) is part of an epidemic of heterosexually spread AIDS that doctors here at Uganda's largest hospital are now describing as a public health "disaster" in this East African country.
Blood tests in Kampala in the past six months indicate that at least 10 percent of the capital's sexually active population is infected with antibodies of the Acquired Immunity Deficiency Syndrome virus, which destroys the body's natural immune system.
In Uganda, where the variety and frequency of infectious disease is far greater than in the developed world, AIDS patients are dying of ailments ranging from common diarrhea to tuberculosis, from rare cancers to brain infections. Most AIDS patients die from infections and diseases that take advantage of their weakening immune system.
A survey of 1,011 pregnant women in Kampala found that 13.6 percent were positive for the AIDS virus. Another study of 370 blood donors in the city found that 10.8 percent were positive for AIDS. A study of 70 2-year-old children with measles found that 10 percent had the virus. Not all those who test positive for the AIDS virus show symptoms of the disease, and doctors here say they do not know if all those who have the virus will eventually become ill.
AIDS is now the leading cause of death in the internal medicine wards at Mulago, where one of every 10 new patients shows symptoms of the disease, according to Dr. J. Wilson Carswell, chairman of the hospital's clinical committee on AIDS. One estimate indicates there were about 200 cases of AIDS at Mulago Hospital last year. In the first four months of this year, Mulago reported 285 new cases.
"We have got a human disaster situation like the eruption of Mount St. Helens, like the Mexican City earthquake," said Carswell last week. "We are seeing a doubling in new cases every six months."
"Five years ago, in 1981, no cases were seen" at Mulago Hospital, Carswell wrote in a recent report. "Two years ago, in 1984, one or two cases a month were being seen. Early last year, one or two cases a week were being recognized, while by the end of last year an average of one case a day was being admitted. Now, two or three cases a day are being seen."
Another report by Carswell and four other doctors at Mulago said that AIDS patients who show up in hospitals "must represent only a small fraction of the total number of cases in Uganda, where medical recording is currently very poor and where many patients will not come to hospital for a disease they regard as hopelessly fatal." The doctors say epidemiological research outside of Kampala is urgently needed.
Belgian researchers last year documented what they called an alarming increase in AIDS in bordering Zaire and Rwanda. They said the disease, which in the United States is confined almost exclusively to homosexuals, intravenous drug users and recipients of contaminated blood, is spreading chiefly among heterosexuals in Africa. Homosexuality is believed rare in central and eastern Africa.
The Belgians also found that sexual promiscuity plays an important role in the spread of AIDS, which in Africa affects men and women in equal numbers. In one study of 58 men with AIDS, 81 percent said they had regular contacts with prostitutes and had an average of 32 sexual partners a year. In Rwanda, 80 percent of prostitutes surveyed were found to have been exposed to the AIDS virus. Another study last year of 90 prostitutes in Nairobi, the Kenyan capital, found that half were infected with the virus.
Only in the past few months, however, as Uganda has begun to rebuild from nearly two decades of government-inspired violence and civil war, have doctors here been able to begin to chart the extent of the AIDS infection in this country of 14 million people.
Doctors and some government officials here say that the years of fighting and insecurity, while claiming an estimated half million lives and wrecking the country's roads, hospitals and public services, also have eroded public morality and helped create a promiscuous society that is highly susceptible to AIDS.
"There is profound promiscuity in Uganda and a virus that takes advantage of it," said Dr. Richard Goodgame, an American gastroenterologist who works at Mulago and is one of the doctors who has been studying the disease here. "The average Ugandan has sex with great frequency and with a great number of different partners."
Nathan Epenu, director of information for the government of President Yoweri Museveni, who seized power in a coup this January, said last week that the years of "insecurity were such that morals and family values have broken down."
During the rules of former presidents Idi Amin and Milton Obote, government soldiers frequently raped women from outside their tribes. The breakdown of the country's economy made it impossible for many people to afford the "bride price" of several cattle that is traditional for a Ugandan marriage. Consequently, informal and often temporary liaisons have become the norm, according to Josephine Wanja Harmsworth Andama, a social anthropologist who has done family research here for the United Nations and the U.S. government.
Cole Dodge, head of the U.N. Children's Fund here, said the years of fighting have forced many women to move into towns, where they pursue "lives of greater economic and sexual freedom."
While previous Ugandan governments have suppressed news of AIDS (first reported in southwestern Uganda in 1982), the new government has decided to embark on what the minister of health, Dr. Ruhakama Rugunda, says will be a program of "mass public education" to head off the disease. In a recent meeting with U.N. health officials in Geneva, Rugunda described AIDS as one of the country's major health problems.
"There is no national pride whatsoever in hiding the prevalence of AIDS," Rugunda said last week in an interview. "If anything, in my view, you objectively destroy the standing and pride of your country if you hide such a problem."
Rugunda's openness on AIDS stands in marked contrast to positions taken by health officials in several neighboring African countries. Late last year, Zaire and Burundi chose not to present data to a meeting on AIDS sponsored by the World Health Organization.
The government's financial capacity to head off the spread of AIDS -- by massive education, by screening blood donors, by distributing condoms -- is severely circumscribed. According to the World Bank, Uganda spends about $1.60 per person annually on health care. That is roughly the cost of one blood test for AIDS. Rugunda said the country also has epidemic levels of measles, sleeping sickness and malaria.
Most of the AIDS research here has been carried out without government funding. Mulago Hospital surgeons, heart specialists and pediatricians have volunteered their own time and money to gather blood samples and send them off for testing in London.
When AIDS patients come to the government-owned hospital, most of them are told they would be better off at home. Parts of the hospital have had no electricity for three months. Water is often unavailable. The staff has no rubber gloves.
Until two weeks ago, the country had no machines for screening blood donors for AIDS. One machine now is in operation and two others have been ordered with money donated by the European Community. Mulago Hospital still has no way of screening the AIDS virus from its blood bank. Doctors say transfusion recipients have an 11 percent chance of getting the virus.
Alarmed by the threat of AIDS, the U.S. Embassy in Kampala is authorized to send its employes and their dependents out of the country even for routine dental care that requires an injection. Some U.N. agencies here have put together their own private blood-donor systems.
For Ugandans, the minister of health says the government needs help from the international community to help pay for a mass education program targeted at sexually active young adults and children.
The government's message, as detailed in a new poster on the streets of Kampala, warns Ugandans to limit the number of their sexual partners and to use condoms.
The minister of health said last week that "fear of AIDS" already has begun to change sexual behavior in Uganda. He acknowledged, however, that getting rural Ugandans to use condoms will be a problem. "The condom is a foreign thing to them," he said.