Sooner or later, everyone is going to die anyway
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* Ellen M. Einterz

Yagana (as I will call her) is the widow of a truck driver who died of AIDS, and as I write this she is languishing in our isolation ward in Cameroon. She has AIDS and tuberculosis, and weighs 28 kg. Although she can sit for a few minutes at a time, she cannot stand at all. Her older brothers dropped her off a month ago, left and never came back.

As in most rural hospitals in Africa, patients' families are responsible for the feeding and nonmedical care of sick relatives. To care for Yagana, the brothers left her daughter, Falta. She does all the cleaning, bathing, laundry and water fetching for her mother and herself, and brings whatever food she can find. She massages her mother's wasted limbs and chats with her in a lively voice about things she has seen and done out beyond the ward.

Yagana is 23 years old. Falta is 41/2.

AIDS remains shrouded in myth and mystery in this part of Africa, where these patients are isolated, shunned and often encouraged to die. An educated man who suspected he had AIDS travelled 100 km from across the border in order to be tested at our hospital. I asked why he had come so far. “Where I am from,” he replied, “if the doctor sees you have a positive test, he takes you in the back room and gives you an injection and you die.”

A death in the family is never attributed to AIDS. Instead, the-doctor-said-it-was-typhoid or they-told-us-it-was-malaria. Sometimes, in this society where heterosexual contact and vertical transmission account for the huge majority of AIDS cases, there is an almost willful ignorance. Until very recently, a large chunk of Cameroon's corps of civil servants — the country's elite — were denying the existence of AIDS. The French acronym, SIDA, was dismissed with a smirk as *Syndrome Inventé pour Décourager l'Amour.*

Such ignorance is deadly, yet because of the multitude of languages spoken in our area, the absence of a lingua franca and the exceptionally high rate of illiteracy, even aggressive public health campaigns have limited impact. Outside the major cities, televisions are all but nonexistent, radios are rare and those few who read have no reasonable access to newspapers or magazines. There are no libraries; few teachers and fewer students have books.

AIDS is not yet rampant enough here to be recognized as the voracious plague it is elsewhere in Africa. Our cases are still sporadic and remain largely within the nuclear family — husband, wife, children — as if the household were doomed by a witch's spell. Long-distance drivers, soldiers and policemen, and men who leave their homes for months at a time to work in distant cities as labourers or night watchmen, are important vehicles of transmission. It is not easy to convince these healthy, vigorous people of the potential danger they face or the devastation they risk bringing back to the village.

Ignorance is abetted by a culturally ingrained and pervasive fatalism that is, like gravity, an overwhelming force. God alone decides when a person should fall sick, and it is impertinent, ridiculous, to imagine that His will can be impugned.

In addition, marriage is a loosely defined institution in Cameroon. Even among the educated, few couples are married by law, and separation, divorce and remarriage are common. Polygamy is practised by the adherents of traditional religions, as well as by Moslems and Christians alike. Prostitution is a thriving and unhidden commercial enterprise, and although sexual promiscuity of never-married girls or women in stable relationships is socially abhorred, male promiscuity is accepted as an inescapable fact of life. Prenuptial testing for HIV might offer a measure of prevention, but society scorns it as insulting and dishonourable.

Some of the savvier women know they are at risk, but they also know they are trapped. “What are we to do?” a soldier's wife asked me recently. “Tell our men to wear condoms when they come home? I know what my husband does when he is away. I can warn him but I can't stop him. Am I to divorce him, leave my children? And then what?”

Faced with an impossible choice, it is easier to ignore the problem and get on with life, whatever it might bring. Sooner or later, everyone is going to die anyway.

For now, treatment is not an option for any of our AIDS patients. The drugs are not available, but even if they were and could be procured at cut-rate prices the cost of lifelong treatment — medicines, monitoring and complications — would still be so exorbitant that things would change very little.

Is there any hope? Until that distant day when a safe, effective and affordable vaccine is developed, nothing short of a seismic shift in values is likely to reverse the current trend. For that to happen in areas like ours, it is probable, as the saying goes, that things will have to get a lot worse before they get worse. Then, maybe, they will start to get better.

Meanwhile, the only certainty is that the suffering that awaits the Yaganas and Faltas of our world is almost unimaginable.