Multinational Monitor

MAR/APR 2007
VOL 28 No. 2


Big Pharma and AIDS Act II: Patents and the Price of Second-Line Treatment
by Robert Weissman

Manuel Cossa's Story: Mining and the Migration of AIDS
by Stephanie Nolan

Slow on Generics: Bush Policy Saves Lives, At a Premium
by M. Asif Ismail

HIV In Uganda: The Challenges of Getting Pills to Patients
by Richard Kavuma

Building Up Baja: US Suburbanization Comes to the Peninsula
by Dan La Botz


Cry for Action: Shameful Neglect and the Search for Hope in AIDS-Ravaged Africa an interview with Stephen Lewis

Four Million Short: The Healthcare Worker Shortage
an interview with Lincoln Chen


Behind the Lines

Deadly Dictates: The IMF, AIDS and the Healthcare Crisis

The Front
Climate Changing Africa -- African Inequality

The Lawrence Summers Memorial Award

Greed At a Glance

Commercial Alert

Names In the News


Manuel Cossa's Story: Mining and the Migration of AIDS

by Stephanie Nolan

Xai Xai, Mozambique - When Manuel Cossa came home from the mines, he brought a pair of green flip-flops, a battered pair of trousers, a white collared shirt worn and washed almost to transparency. And a wrenching, tearing cough that left him bent double, with tears in the corners of his wide eyes.

It was painfully little to show for a life spent in grueling labor underground, and not the way Manuel imagined he would come home. Men who went to work in the mines used to return on visits with smart city clothes and gifts for their families - mattresses, enamel cooking pots and perhaps portable stereos. When they came home to Mozambique for good, after a decade or more in South Africa, it was with a fat packet of wages that they used to put sturdy tin roofs on their houses, to buy dark wooden tables and chairs with stiff upholstery, to put a cement floor in the latrine in the yard.
But these days, more and more of the miners come home without any gifts, without any savings, without any cash. They come home like Manuel did: thin and worn and racked with pain. Or they don't come home at all.

I met Manuel in Xai Xai, a sleepy town set between the Indian Ocean and the muddy Limpopo River in central Mozambique, more than a hundred miles north of the capital, Maputo. A great many of the men from Xai Xai (pronounced Shy Shy) work in the mines in South Africa, and the men folk were gone from most of the houses. Manuel, however, was home. He couldn't get up to greet me from the green plastic chair where he sat stiff with pain, but he invited me to sit, and I joined his wife, Philomena, on a woven grass mat in their neatly swept yard. He spoke slowly in Tshangaan, his words punctuated by terrible fits of coughing that made Philomena and me flinch, and he told me how a boy from a farming town ends up spending his life underground digging for gold in a city far away.

When Manuel turned 18 in 1967, he became eligible for conscription into the army of the Portuguese colonial rulers, which was fighting the rebel Front for the Liberation of Mozambique (FRELIMO). Manuel didn't want to fight, and so he went to the poky office maintained by a mining recruitment service right there in his small town. Within minutes he had a job - a job he couldn't begin to imagine in a country he had never seen.

When gold was discovered in 1866 beneath the ridge of earth that is now Johannesburg, white miners staked out the first jobs. But the gold was sparsely distributed through the earth - as far as three miles underground - and so a massive amount of dirt had to be hauled to the surface and sifted, and soon the mines were hungry for cheap black labor. Black people, driven off their land by white farmers and settlers, had begun to flood into the city in search of jobs. To keep control of the black population, and prevent permanent black settlements from developing, the government ordered the men to come alone and live in hostels right at the mines, leaving their families back in distant villages. The miners would work for a few years, and then - often when they were injured, worn out or in the early stages of the lung disease silicosis - sent back to their rural homes, to be replaced by a new crop of young men. It was the beginning of South Africa's hated apartheid "pass system," which allowed only black laborers with passes into white areas, restricting the rest to regions designated for black occupancy.

The mines had a rapacious appetite for labor, which led to the development of a migrant flow that at its height drew more than 750,000 men from all of South Africa's bordering countries, plus Zambia, Angola, Malawi and as far away as Tanzania. Similar patterns developed across the region: men journeyed hundreds of miles from Malawi and Lesotho to work in the diamond mines at Kimberley; from Zimbabwe and Mozambique to the copper mines in Zambia; from Botswana to the coal mines of Zimbabwe. By the 1960s, South Africa's mines had workforces that were more than 80 percent foreign - because the foreign men could be sent back across the borders when the mines were done with them, and because the mine bosses believed that some ethnic groups, such as the Basotho people of Lesotho, were easier to control than others. The men kept coming because the mines and the agricultural plantations were just about the only sources of waged labor available to black men in southern Africa through most of the last century.

Manuel was one of tens of thousands of Mozambicans who headed for the gold mines. As a boy, he had finished only three years of primary school before he had to help his father work their small patch of land. There was no work at home. "If I'd stayed here I could only have made grass baskets or floor mats. It helped me - I managed to feed my family."

He was gone for almost all of the next 37 years, spending his nights up to half a mile underground, driving a cart through the humid, dimly lit tunnels along the veins of gold, picking up the rubble left by the blasting crew who worked days. He was a "scrap driver," one of just a handful of words he knows in English. He worked, most of those years, for West Rand Consolidated Mines and Stilfontein Gold Mining. The record of his employment, a bland list of new contracts every year or two, was so well worn it fell to pieces when he handed it to me. He smiled a bit when I asked him how he felt about the work in the mines, which are legendarily hot and dangerous (one in every 25 miners dies on the job, and fully half of miners have a permanent disability by the time they stop mining). "I liked it because they paid for it," he said simply. His top wage, after 25 years in the mine, was 60 rand, or $10 a day. But it wasn't easy, especially not in the early years. "In those days, a person could die like a dog and just vanish without anyone knowing where he was. It wasn't like today, when things are more organized and they have unions to protect people. But the white people didn't allow you to complain. It was like being a slave."

His contract was like all the other miners': he was allowed one home visit every 18 months. "Sometimes my husband would come home for a month or six months and stay with me," Philomena said, with a fond glance at Manuel. But it was rarely that long, he explained: "You had to ask the company for leave to come home - sometimes you got 10 days and sometimes a month." And of course he didn't get paid for those days away from work. But he was proud that he was not one of those men who left for decades. "I never stayed more than two years away without coming home."

Manuel was already a miner when Philomena was introduced to him by her family in the early 1970s, so she knew he would be going back to South Africa. "But I didn't know he'd be gone so long," she said wistfully. Even today she has little idea what his life was like there - she has "not one clue" about South Africa, she said. The lengthy absences were difficult for Manuel, and hard on his family. "I missed him," Philomena told me shyly, eyes fixed in her lap. "But I got used to it. I took care of the house and I did the farming and I knew my husband was working. Of course it's not a good thing to be apart so much time, but someone who goes away to work is going to bring something back. You can go to the fields around here and work and you'll get food, but no money to buy a bed or buy clothes - so what can you do?"

Manuel never earned enough to put up brick walls or a zinc roof, but the Cossa home has three separate buildings with reed and wattle walls. The family has proper wooden beds, rather than mats on the floor, and everyone has a few changes of clothes. He brought home a bicycle for his middle son, Mario, one year, and a cell phone that his daughter, Elisa, likes to carry around - she charges it at the home of neighbors who have electricity.

When he left for the mines, Manuel traveled 12 hours west by shuddering, wheezing bus from Xai Xai on the lush Mozambican coast to the cool highveld. Through all his years in the mines, he lived in what's called a hostel, the mining industry's solution for housing the rotating crops of single men. The hostels are rows of rectangular rooms, each about 20 feet square, in which 20 men are each allotted a bunk and a cupboard. Hostels afford their residents no privacy; they are, Manuel said, one of the worst things about the job. In the daytime, there wasn't a great deal to do. Some of the men played soccer in a rough field outside the hostel, and Manuel watched their matches. He did errands in the rough trading center near the mine, and took a sewing class there, so that he could make a bit of extra money doing mending and alterations for other miners. There was a large open bar on the mine property that sold big cartons of potent sorghum beer. And there were women: none on the mine property itself, but plenty standing just outside the chain-link fence. Lots of them sitting in the shade of the low scrub trees in the fields across the road from the mine. And a great many, smiling and ready to drape an arm over a miner's shoulders, twine her leg with his, in the bars in the ramshackle informal settlement that served the mine. There, women sold sex for about $5 - but when desperate, or when they looked ill, the price could be less than a dollar.

More than half a century ago, South African researchers linked the migrant labor system serving the gold mines to a large hike in the spread of syphilis and gonorrhea. In 1985, South Africa's Chamber of Mines - reflecting the apartheid government's paranoia about AIDS, which was beginning to be reported in other African countries - started testing foreign migrant workers for HIV. When a small group of Malawian miners tested positive, they were immediately expelled. For the next few years, the industry demanded tests of all foreign workers who wanted to come to South Africa, until opposition from unions and foreign governments forced a change in the policy. But by then the genie was out of the bottle: less than 1 percent of pregnant women tested positive for HIV in South Africa in 1990, and almost 30 percent were positive a decade later.

And it is no mystery why, says Mark Lurie, a professor of medicine and community health at Brown University in the United States who has made extensive study of the mining industry in South Africa. "It doesn't take a rocket scientist to figure out that if you wanted to create an HIV epidemic, you would take as many young men as you could away from their families, isolate them in single-sex hostels and give them easy access to sex workers and alcohol. Then, to spread the disease around the country, you'd send them home every once in a while to their wives and girlfriends. The whole subcontinent is connected by people's movement, and infectious disease follows the movement of people."

Lurie has found that male migrant workers are two-and-a-half times more likely to be infected with HIV than non-migrants. The hostels are grim, visits home are rare, the beer and the women are affordable on a miner's comparatively good salary - and, like long-haul trucking, the job is dangerous, giving many men a feeling that they don't need to worry about risk from HIV because they could die any day in a cave-in. Lurie told me that health educators find it difficult to persuade men who work surrounded by such visible danger to worry about a microscopic virus. Many South African mines report that nearly 30 percent of their workforce is infected; studies of the women who work the bars or the open-air brothels in the fields outside the mine fence show they have HIV infection rates as high as 80 percent.

Yet there is also a more insidious way in which migrant labor pushes up infection rates. The problem is not just what happens at the mines but also what happens back home. Lurie has tracked "discordant couples" - pairs where one person has HIV and the other doesn't. In two-thirds of couples, it is the migrant man who is infected - men who buy sex in the years they are away, enjoying the anonymity of the city and behaving in a way they likely wouldn't if subjected to the scrutiny of family and neighbors. But in a solid third of the discordant pairs, it is the woman who is HIV positive - because, of course, the women left at home also have other partners, seeking companionship, sex and often economic support. Many miners strike up long-term relationships with women who live or work in the mining towns, and may start using some of their wages to support those "town wives;" then they may cut back on visits home, or on the money they send. And so the women back in the village take what's called in isiZulu ishende - a man on the side, someone who contributes to the running of the household with school fees or food. All of this widens the circle of infection.

When I met Manuel, he had been home from South Africa for only a couple of weeks. He had been sick off and on for months, and at the mine he had grown so ill that worried friends insisted he take a bus back to Mozambique. (There is a particular, unspoken dread of dying far from home - if family cannot raise the money to bring a body home, a man will be buried in unknown ground far away from his ancestors and those who would tend his grave.) Manuel came home to Xai Xai in October 2005, arriving, Philomena said, "with empty hands." He was thin and gasping and nauseous; he could not walk without help. She went to her church and borrowed 11,000 meticais (40 cents) to pay for him to see the doctor at the local hospital. There, after a long wait on a narrow bench, Manuel was diagnosed with tuberculosis and advised to have an HIV test. Both he and Philomena tested positive.

Manuel seemed calm about the news, perhaps because his pain and fever were occupying most of his thoughts; I sensed he wasn't surprised. "A lot of my friends got ill. There are a lot who died."

Philomena, a gentle woman with an open face and a quiet laugh, seemed more shocked. "I felt bad when I got the result," she said, hands folded in her lap. "But at the hospital I met so many people who had it - some young, some old - that it lifted my spirits: I'm not the only one who has it."

Not the only one, indeed. An estimated 1.9 million Mozambicans, of a population of 18 million, are living with HIV/AIDS. The adult infection rate in the central provinces, source of most of the miners, is 20 percent, the highest in the country.

Mozambique is spectacularly ill equipped to respond to a problem on this scale. The government is struggling, with little money and even less trained staff, to rebuild a health system that was neglected by the Portuguese and destroyed in the savage civil war that evicted the colonizers. In 2004, there were just 450 doctors working in the entire public health system. In May that year the government announced a national ARV treatment program but, only days after beginning, admitted the goal was hopelessly ambitious. "It is simply impossible to imagine that we can distribute ARVs countrywide," said Francisco Songane, the health minister. "We do not have the capacity to do that. We do not have the trained manpower or the infrastructure to handle such a massive program."

The best intentions cannot make a health system out of nothing - and for all that it is often held up these days as a rare African success story, Mozambique is still the sixth-poorest country in the world. After the peace deal in 1992 and the first democratic elections, the former Marxists of FRELIMO became the government and embraced a free-market program drawn up by the World Bank. The country has had remarkable economic growth - an average of 8 percent per year - since that transition to democracy. But the numbers don't tell the whole story: the development is concentrated around Maputo in the south, in a couple of enormous industrial projects. A few hours outside the capital, life looks much like it did 30 years ago. Only 660,000 of Mozambique's 18 million people have formal jobs.

And so the young men continue to make their way to the regional mining recruitment offices and then on to South Africa just like Manuel did. His oldest son, José, left at the age of 20 - he hoped to avoid work underground, but only the mines provide the vital work visa. Their second son, Mario, had no work at home but told me, "I would prefer to suffer here" rather than become a miner.

By the time Manuel came home from South Africa for the last time, he had been troubled by suppurating abscesses on his bony legs for more than a year. He got medicine from the mine doctor, but the lesions didn't heal. He tried the doctor in town, with no more luck. Finally, he went to an inyanga, a traditional healer from Mozambique who was working near the mine. The man made him a remedy, and that healed the sores, Manuel said.

At no time did the mine ever suggest an HIV test. This was a story I heard over and over again in Xai Xai and other villages of central Mozambique. I met Julius Inande, so weak he could not walk when he was relieved of his job and sent home from the Driefontein gold mine, unable to control his diarrhea or close his mouth because of the sores. I met Antonio Titus, who at 34 could not have weighed more than 55 pounds; he tried to hide his wasted body in a soccer jersey that enveloped him like a robe. None of them was ever offered an HIV test, and they had a grim suspicion about why: if a man is sent home with a terminal illness, the mine owes him a package of disability benefits, but if he goes on a "temporary" sick leave, the mine contractually owes him nothing.

Manuel, Julius, Antonio and all the others were the sole wage earners in their families, and the loss of their salaries was devastating. Manuel had no pension and received no sick pay. The family had quickly spent the cash he had brought home from South Africa on the hospital visits, and Philomena found herself trying to feed her family on the unripe vegetables in the garden. In counseling sessions at the hospital, Manuel and Philomena were encouraged to eat well because good nutrition would bolster their immune systems - a bit ironic, Philomena pointed out, "since now we don't have the money even for soap." Their daughter, Elisa, was in Grade 10 and doing well, hoping to be a nurse - but now there was no money to pay the $10 a term to keep her in school, no money for fees for the youngest of their five children, Manuel, to stay in Grade 3, and none for their grandson, Manuelito, to start school at all.

Because mining remains the backbone of South Africa's economy, and because South Africa is the core of the continent's economy (Johannesburg and the mines around it produce 9 percent of the economic output for all of Africa), the relationship between AIDS and mining is not just a social or medical issue but an economic one. In a 2006 assessment of the South African economy, for example, the Economist Intelligence Unit listed HIV/AIDS before any other factor (a volatile currency, powerful unions) as the one to watch in terms of its impact on growth. The big mining companies have been forced to acknowledge that the disease is pushing up the cost of operations - through absenteeism, funeral costs, lowered productivity due to illness, poor staff morale - adding, they say, $10 to the price of each ounce of gold they mine.

In Manuel's last years of work, the companies faced up to the fact that a third of their workforce was infected with a fatal illness. They began to take action, and some South African mining companies have emerged as the global leaders in corporate responsibility for AIDS. They began with comprehensive education programs and condom distribution, but cold economic reality suggested that they were going to have to move quickly on treatment. In 2003, before the South African government had begun public treatment, Anglo American, one of the largest mining firms, rolled out an ARV program that is unmatched in either efficiency or comprehensiveness by any other public or private effort worldwide. These interventions, which involve education, condom distribution and treatment, lowered the cost of AIDS from $10 to $4 an ounce of mined gold, Anglo said. Dr. Brian Brink, Anglo's vice president for medical services, said the reduction of absenteeism compensates for three-quarters of the cost of the ARV treatment program - and since most mines already provide primary health care to their workers, the reduced burden on those facilities pays for the rest.

The other solution was family housing, which Professor Mark Lurie estimates could lower HIV infections by as much as 40 percent. The mines had long resisted this innovation - because of the cost of building houses and of all the services such as schools and clinics that would be needed to serve the families that moved into them - but finally began to give in to the twin pressures of unions and AIDS. In 2005, BHP Billiton moved some of its miners into private or family housing, and turned old hostels into "community centers" to house orphans left by miners and hospices to provide palliative care for the dying. The National Union of Mineworkers demanded greater "living out" allowances so that miners could afford to accommodate their families near the mines or at least rent private accommodation.

But the commitment to these interventions varies wildly between companies; Manuel never saw evidence of any of them, save for some rudimentary safer-sex demonstrations in the bars, and Lurie noted that the vast majority of miners still live in single-sex hostels.

Back home in Mozambique, Manuel learned about ARVs in his hospital counseling sessions. On the day he spent with me, however, he wasn't sure whether the hospital had the drugs or might arrange for him to get them. His torn scrap of paper from the local clinic said he had oral thrush and the skin cancer Kaposi's sarcoma; the inside of his eyelids were chalk white, a sign of severe anemia, which is also common in people with HIV. When he produced his plastic bag of pills, I saw that he had been given vitamins and the antibiotic cotrimoxazole - but no ARVs.

Manuel and Philomena were gracious with my questions, but our conversations about AIDS - about how they had come to be infected, and about fidelity in the course of their long marriage - were circuitous and oblique. "Life in South Africa is very tough, but it's not just a matter of relations with a woman," Manuel said cryptically. "I think you can get HIV through an apple or an orange or an injection or anything. Not necessarily through relations with a woman."

Philomena said that it was "possible" Manuel had become infected in South Africa, but then she added, her eyes fixed on mine, "He was a serious man when we met and he's always been a good man."

Because Manuel's illness was so much more advanced than Philomena's, who said she felt quite well, he had likely been infected before passing HIV to his wife, although it is also possible that she was the first to be infected.

In the soft light of late afternoon, looking into the middle distance, Manuel told me he was sure that Philomena always "waited" for him when he was away. Whatever suspicions they had about how HIV got to their family, the time for accusations was past.

Though he was in obvious pain, Manuel and Philomena laughed together when they told the story of their first meeting and how they quickly decided to marry. "I went to see her and thought, she's the right one for me," he said. Then he just had to hope she would agree: "When you're concentrating like that you can even forget about food." But Philomena was quick to accept his proposal: "I wanted to build a family with him."

They did build a family, and she grew their food and raised their children while he earned money to house them and bring precious presents back from the city. And, Philomena said, she was glad he had come home again. No matter what he had brought with him.

Stephanie Nolan is the award-winning Africa correspndent for Toronto's Globe and Mail and the only Western journalist currently dedicated to solely covering AIDS in Africa. She was the recipient of the 2003, 2004 and 2006 Amnesty International Award for Human Rights Reporting. Excerpted from 28 Stories of AIDS in Africa. (c) 2007, Stephanie Nloan. Reprinted by permission of Walker & Co.

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