Journeying through an epidemic

The vast proportions of the HIV and AIDS epidemic signify that it touches millions of lives in every corner of the world. Three Letter Plague is Jonny Steinberg’s enthralling investigation into HIV and AIDS in South Africa, discovering why the AIDS epidemic will proliferate and continue to decimate the population, even with the significant advances in anti-retro viral drugs and healthcare education.

Three Letter Plague is Jonny Steinberg’s illuminating enquiry into the great epidemic of our times — HIV and AIDS. His absorbing tale is one of immense significance, which began with a simple premise. Why were so many people dying of AIDS in Steinberg’s native South Africa when they were located within walking distance of treatment? The answers Steinberg finds are complex and deal with the relations between people, institutions and communities.

Steinberg was born in South Africa in 1970. He is a prize-winning journalist and writer, and was awarded a Rhodes scholarship in the mid-1990s to study at Oxford University, where he graduated with a doctorate in political theory. Steinberg returned to South Africa and worked for the South African daily newspaper, Business Day. He has twice won South Africa’s prestigious literary prize, the Sunday Times Alan Paton Award for non-fiction for his books, Midlands (2003) and The Number (2005). He explains: “I was living in the UK from 1995 to 1998 and it was the beginning of South African democracy. It was a big time in South African history and it was affecting daily life everywhere in strange and unexpected ways. These changes were barely being written about. It was a situation where you could go and stand on any corner, visit any village, or household and see something fascinating happening. It was all waiting to be documented, so that is what I tried to do for 10 years and in the space of four books, to look at various aspects of life and how it was changing.”

The vivid prose that Steinberg utilises identifies the HIV and AIDS pandemic in the distinctive environment of post-apartheid South Africa. Steinberg became inspired to write Three Letter Plague after reading Edwin Cameron’s book, Witness to AIDS, a particularly tragic story of Botswana. In 2001, the government in Botswana realised that around 100,000 of its citizens were in urgent need of treatment for HIV, or they would face death. The government took the remarkable step of making HIV treatment universally available, the first country in sub-Saharan Africa to do so. Steinberg comments: “Two years later, in Botswana only 15,000 people had come forward and for treatment and the rest had stayed at home and were either dying or dead. In an awful sense they had chosen to die, rather than reveal that they had this shameful virus. South Africa had been fighting this monumental struggle against our government to make this medicine available and I just wondered — what happens when it becomes available? Are people going to get it or not?”

The statistics that Steinberg quotes about HIV in South Africa are astounding. Almost 6 million people are HIV positive, in an overall population of 46 million. On average 800 South Africans die from AIDS on a daily basis and the new daily infection rate is 1000. HIV and AIDS are decimating all age groups of the South African population, but in particular young people. In Three Letter Plague, Steinberg concentrates on Lusikisiki, a picturesque rural district in Eastern Cape, South Africa. It consists of around thirty villages and is an area steeped in poverty and home to 150,000 residents. Steinberg wanted to find a location where good anti-retro viral (ARV) treatment (to prevent the replication of the HIV virus) had recently become available and Lusikisiki matched his criteria. One of the villages Steinberg visits is called Ithanga. Here, like in many villages in the district, there is only one shop to serve the whole village. This shop is run by Sizwe Magadla, a 29 year old Ithanga resident.

Steinberg employs Sizwe as his translator and together they visit the clinics, which in association with Médecins Sans Frontières (MSF) and the enigmatic Dr. Hermann Reuter had begun a programme of HIV testing and the dissemination of ARV medicine, which was prolonging and most importantly saving lives. There was a debate going on between the South African government and MSF about the best way to deploy treatment to the people. The government wanted it to be done through hospitals, but MSF’s response was immediate. Due to the expansive nature of the epidemic, the ARV medicine had to be provided at a grassroots level in simple local institutions through laypeople and nurses, otherwise people would die waiting in the queues at hospitals. “Herman’s task was to try to bring the clinic’s people to life and make them treat the epidemic. When they arrived nurses were in total denial and said that there was ‘no AIDS here’ and even by the time he left many nurses were treating people badly and rebelling against huge workloads. The interface between service providers and institutions was mixed and the task MSF faced was to maintain that relationship. Their main strategy was through laypeople — to bring in very idealistic young people in their early 20s and to flood them in the clinics and borrow their energy to keep the clinics alive and running.”

Steinberg is adept at describing the relationship between people and institutions, but this runs parallel to another great strand of Three Letter Plague, where Steinberg unravels the complex reactions that black South Africans have to western ARV medicine in post-apartheid South Africa. We see this through the eyes of Sizwe and his own reaction to the prospect of testing for HIV, as they undertake the journey through ARV medicine in the Lusikisiki district. “I had employed Sizwe to come to clinics with me to check out the ARV programme. Around medicine he had a defensiveness and a wariness of me, much of the book is about breaking through that and seeing why. What comes out is a great deal of racial hurt and this idea that the epidemic is an attack on black people by whites, and that was very difficult for Sizwe to share that with me. There was a deep sense of masculine shame, the idea that this is a virus, which is not just in your blood, but also in your semen and something that you will transmit to your children and poison the next generation. In a context like that it really hits men very hard, and it took me a while to understand that was where his reticence was coming from.”

Steinberg deconstructs the mythology surrounding HIV in South Africa, from the many rumours about HIV being carried in the needle of the doctors when they test you, or that HIV isn’t spread through sexual intercourse, a sentiment endorsed by former South African President, Thabo Mbeki. Other people believed that you become infected with HIV by demons that are sent to punish you. “The history of Western medicine and poor black people in South Africa is very complicated. There were a lot of inherited memories of where medicine has been dangerous, where it has been lethal, when it had come with power and destruction. People carried that history with them when they saw this ARV programme. Much of the programme’s success was about transcending that history and trying to win some trust and it was fascinating watching that process.”

The sense of racial hurt is prevalent throughout Three Letter Plague. Sizwe strives to find cures to HIV and AIDS from within his own community, so that people would not have to use the western ARV medicine to treat HIV. The experience of apartheid is bound up in people’s responses to both the origins of HIV and the ARV treatment programme. “People understand HIV through the prism of having experienced apartheid. They see that they come from poor underdeveloped communities and especially men have experienced apartheid as a gradual process of emasculation over generations. They had land taken from them and then had to do menial work and then having that taken from them. AIDS is the ultimate emasculating experience; it really hits the heart of everybody’s sense of manhood. For people like Sizwe, it links to a history of racial oppression, they can’t separate the experience of AIDS from the experience of apartheid; it is all bound up together.”

Steinberg’s compelling account tackles the global issue of HIV and AIDS at a localised level. It is a complex and eye-opening journey through the responses to HIV — from the various instances of stigma, to unexpected people embracing the ARV treatment programme. Three Letter Plague is both educational and deeply humanises an epidemic that is too often thought about as statistics as opposed to people’s lives.

Three Letter Plague was published on 15 January 2009 by Vintage.

Shona Fairweather