The Vanishing Mothers of Africa

Editor's Note: The following is adapted from Stephen Lewis's keynote speech at the 2004 Microbicides Conference.

If there's one constant throughout the years I've been U.N. Special Envoy – years spent traversing the African continent – it's the thus-far irreversible vulnerability of women. It goes without saying that the virus has targeted women with a raging, Darwinian ferocity. It goes equally without saying that gender inequality is what sustains and nurtures the virus, causing women to be infected in ever greater, disproportionate numbers.

The report issued by UNAIDS on the eve of the 2002 International AIDS Conference identified startling percentages of infected women. UNICEF's Carol Bellamy used a phrase there that would become a mantra: "AIDS has a woman's face."

Women's acute vulnerability didn't happen overnight. What should shock us is how long the world took to focus. Why was it only in 2003 that a U.N. Task Force on the plight of women in Southern Africa was appointed? Why did it take until 2004 to form a Global Coalition on Women and AIDS? Why have we allowed a continuing pattern of sexual carnage so grave as to lose an entire generation of women and girls?

In 2003, Botswana did a study on HIV prevalence. In urban areas, for women and girls ages 15 to 19, the prevalence rate was 15.4 percent; for men and boys the same age, 1.2 percent. For women between 20 and 24, the rate was 29.7 percent; for men that age, 8.4 percent. For women between 25 and 29, the rate was 54.1 percent; for men, 29.7 percent. The reason we've observed – and still do, without taking decisive action – this wanton attack on women is because it's happening to women.

African countries, external powers, bilateral donors, even the U.N. – no one shouted from rhetorical rooftops or called an international conference, although in the 1990s it seemed that all we had time for were international conferences. This is the ultimate vindication of the feminist analysis. When the rights of women are involved, the world goes into reverse. For more than 20 years, the numbers of infected women grew exponentially.

Now, virtually half the infections in the world are among women – and in Africa the rate is 58 percent, rising to 75 percent between the ages of 15 and 24. This is a cataclysm. Yet while finally (after the doomsday clock passed midnight) we're starting to get agitated, little is changing. Believe me; on the ground, where women live and die, very little is changing.

A few years ago, I visited the prenatal health clinic in Kigali, Rwanda, meeting with women who had decided to take a course of nevirapine. They were excited and hopeful, but asked a poignant question: "We'll do anything to save our babies, but what about us?"

Back then, more than four years after antiretrovirals were in widespread use in the West, we simply watched the mothers die. Today, thanks to the Columbia School of Public Health, funded by several foundations and USAID, and working with the Elizabeth Glaser Foundation, UNICEF and governments, the strategy of PMTCT-Plus (Prevention of Mother to Child Transmission Plus) has begun in several countries, where the "Plus" represents treatment of the mothers and partners – indeed, the entire family.

But it's a slow, incremental process. In principle, the majority of such women will one day fall under public antiretroviral treatment through their ministries of health. But there's no guarantee of when, or if, that day will dawn. It's entirely possible that men will be at the front of the bus. Everything proceeds at a glacial pace when responding to the needs and rights of women.

We deplore patterns of sexual violence against women – violence that transmits the virus – but the malevolent patterns continue. We lament the use of rape as an instrument of war, but in eastern Congo and western Sudan, possibly the worst-known episodes of sexual cruelty and mutilation are occurring, and the world barely notices. We see Rwanda's women survivors, now suffering full-blown AIDS, demonstrating how such stories end.

Nearly half of the HIV cases in the world are women. In Africa, it's more than half, and young women bear the brunt of the pandemic

We talk of amending property rights and introducing laws on inheritance rights, but I've yet to see marked progress. We speak of paying women for unacknowledged, uncompensated work; ushering in a cornucopia of income-generating activities. In a few places this is happening, especially where local women's leadership is strong enough to take hold. But mostly, in Churchill's phrase, it's "Jaw, jaw, jaw."

For much of my adult life, I've felt the gender-equality struggle is the toughest struggle of all. Never have I felt it more keenly than in the battle against HIV/AIDS. The women of Africa (and elsewhere) run the household, grow the food, assume virtually the entire burden of care, raise the orphans, and do it all with unimaginable stoicism. As recompense for this life of hardship and devotion, they die agonizing deaths.

While it's possible that we'll make more progress over the next five years than in the past 20, I can't emphasize enough how the inertia and sexism that plague our response are almost indelibly ingrained. People ask, "What about the men? We have to work with the men."

Of course we do. But please recognize that it will take generations to change predatory male sexual behavior. The women of Africa are dying today. Which is where microbicides come in. I'm not pretending they're a magic bullet or vaccine, or that we can forget cultural change is urgently required. But when the landscape is so bleak, the prospect of a microbicide in five to 10 years is intoxicating.

That women will have a way to reassert control over their sexuality and defend their health, have a course of prevention, perhaps have a microbicide that prevents infection but allows for conception; that women can use microbicides without bowing to male dictates – indeed, men won't even know the microbicide is in use – these are ideas whose time has come. Resources of the international community should flow, torrentially, toward this end.

Microbicides as a solution would pale if we were making progress on other fronts. But we're not – or we are, but in tiny installments. I don't know how to convey what's happening out there. I travel from country to country, through rural hinterlands, seeing project after project. Everywhere the lives of women are compromised. How do we get governments, international financial institutions and bilateral development donors to understand? It's not changing.

Certain incidents sear themselves into the mind. A grandmother, age 73, in Alexandra Township, Johannesburg. She lost all five of her children between 2001 and 2003. She tends four orphans, all HIV-positive. She's one of the legion of African grandmothers who, in a reversal of life's rhythm, bury their children and then, heroically, raise their grandchildren. In Uganda, a child-headed household: a girl of 14, who cares for two sisters, 12 and 10, and two brothers, 11 and 8. This is common across the continent. The mothers are gone.

At a clinic in Zambia, where mothers come for testing and the possible use of nevirapine during birth, the women say: "You have drugs in your country to keep your people alive. Why can't we?" I don't know how to answer this question about one of the ugliest chasms between the developing and developed world.

In Swaziland, I trek into the bush to visit a small community of women living with AIDS, caring for hordes of orphans. They lead us to the home of a dying woman. I've spent a lot of time in huts where women lie dying. But I've never seen anyone this ill, her face a mask of death: a young woman – they're always in their 20s – valiantly raising her head a few inches to acknowledge visitors.

Her children are watching her die. That's what children in Africa do: become orphans while their parents are dying. Then they watch the death itself. Then they attend the funeral. I'm filled with a rage I can barely contain, though I know it reduces my effectiveness. The madness – that what's happening is so unnecessary, that we could subdue this pandemic if the world put its mind to it – renders me almost incoherent.

I ask that you see microbicides not merely as one of the great scientific pursuits of the age, but as a significant emancipation for women whose cultural, social and economic inheritance have put them so gravely at risk. Never in human history have so many died for so little reason. It must not continue.

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