OSI Stories: A Struggle Against Illness and Neglect in Swaziland

By late afternoon on the last Thursday in November 2007, King Mswati III, monarch of Swaziland, was reigning over a million souls in his predominantly Christian realm landlocked between the eastern edge of South Africa and the southern stub of Mozambique. The world’s worst pandemic of HIV/AIDS had combined with diseases like tuberculosis, meningitis, and pneumonia to slash the life expectancy of Swaziland’s citizens to just 31 years.

About half of the kingdom’s pregnant women, and about half of all its women between the ages of 25 to 29, are HIV positive. In just a decade and a half, tuberculosis, which ravages people with HIV/AIDS, has increased more than sixfold in prevalence. About 130,000 of the kingdom’s children—13 percent of its overall population—are orphans. And as the summer sun descended over Swaziland on that November afternoon, three Swazis—an emaciated 39-year-old woman named May and two of her daughters—seemed about to deliver themselves to the statisticians.

A barren avocado tree shaded May and her daughters as they sat in front of a hut of crumbling red-mud bricks. HIV was coursing through her veins. A cough erupted from the depths of her chest, muffled by a kerchief cupped over her mouth. The little girls were surviving on a bowl a day of bean porridge from a nearby drop-in center for orphans that is closed on weekends. “I have only whatever food the children bring me,” May said. Somehow, perhaps because she was too weak, her words lacked the whine of a complaint.

In patriarchal Swaziland, women like May have little choice but to submit to men. More than 60 percent of Swaziland’s women between the ages of 17 and 24 have already suffered sexual violence sometime during their lives.

“All the Ills Are Blamed on Women”

“All the ills of society are blamed on women,” said Doo Aphane, director of the country’s Lutheran Development Service. “Wives cannot demand safe sex. Men can marry as many wives as they want. The king marries 16-year-olds, and other men are envious. Young girls are infected by older sugar daddies. There is a lot of incest and violence. Much of the government’s inability to deal with the health consequences of the abuse of women is rooted in lack of good governance and massive corruption.”

Despite the odds, May worked to improve her family’s situation by taking a temporary job in a distant garment factory after two of the men who fathered her children abandoned the family. A third father, the only one to beat May, left the family a year or so ago.

“Their father left before I found out I was HIV positive,” May said. Before another eruption of coughing, she accused him of infecting her: “After each time he came around I would develop a rash with pus.”

By that November afternoon, HIV had eroded May’s health and she could no longer work and had no income. Had she died that evening, her daughters would have had no support beyond porridge from the drop-in center: No relatives willing to take them in. No state orphanage. No metal roof over a hut of red-mud bricks with a soggy bed inside.

A Disaster Unfolds

In 1993, public health officials had cautioned Swaziland’s parliament and government that, if the HIV/AIDS outbreak went unchecked, it would ravage the country’s population. Members of parliament shouted down the warnings; they accused the health officials of toying with them.

“It is amazing how closely we got it right,” said Rudolph Maziya, who helped present the report and is now director of AMICAALL, a community-action organization collaborating with the Open Society Initiative for Southern Africa to fight HIV/AIDS. After the report’s release, the government, which works under the royal thumb (as Swaziland’s laws, civil and traditional, make King Mswati’s will absolute), took no effective action. As the epidemic careered out of control, the king purchased new BMWs and Mercedes Benz sedans for his family and pursued a fixed routine of age-old rituals and traditions. He took new teenage wives. He fathered new children.

It was 1999 before King Mswati declared Swaziland’s HIV/AIDS epidemic a disaster. On his birthday in 2001, the king barred Swazi women under the age of 18 from having sex for the next five years and ordered them not to wear trousers or even shake hands with men. A few days later, Mswati made a 17-year-old girl his eighth bride. He paid a fine of one cow for violating his own decree.

During 2003, ARVs, the antiretroviral drugs that block the onset of AIDS, became available in significant and affordable quantities in many parts of Africa, including Swaziland. By that last Thursday in November 2007, about 28 percent of the HIV-positive people in Swaziland who require these medications were actually getting them. May was among the 72 percent who were not receiving the drugs. Doctors told her she could not receive ARV treatment until she overcame her malnutrition, because the drugs’ side effects would be devastating.

Swaziland’s government health service, like many others in the world, does not consider food to fit the definition of medicine, and it has left May on her own, in a weakened state, to fight against starvation and infectious disease.

Hunger weakens many of Swaziland’s people. Almost 70 percent of the population lingers in abject poverty even as the kingdom’s factories and mines and its sugarcane fields and pulp plants produce significant amounts of foreign currency. Ironically, though the HIV/AIDS pandemic combines with massive corruption by a kleptocratic monarch to impoverish most Swazis and bend the country’s population and economic-growth curves downward, the kingdom statistically still produces enough income per capita to rank it among countries enjoying a middle level of development. This renders Swaziland ineligible for significant international and bilateral funding made available to lesser developed countries, funding that might, if well managed, help lift the vast majority of Swazis like May and her children out of penury.

Who Benefits?

In an air-conditioned office, on the morning of that last Thursday in November, diplomats from a prosperous, and generous, European country asked officials from Swaziland’s government about who was benefiting from the revenues generated by the kingdom’s industries.

“Rich individuals, rich companies, and the rich royal family,” answered one of the officials before making a plea for more financial aid. “We are in the jaws of a pandemic that is not letting up. With the few resources we have, we cannot manage to fight this disease.”

The previous evening the diplomats had heard the same explanation from a large group of Swazi activists. Given the corrupt practices of many Swazi officials, civil society groups are determined to develop new channels for funding that go directly to local and international civil society groups working with the Swazi people. Until these plans are implemented, however, the country’s response to HIV/AIDS remains largely determined by an aloof king.

By the afternoon, the royal palace had announced that King Mswati had gone into seclusion. The time had come for purification. Traditional midsummer rites practiced by many throughout Swaziland were approaching. If the ceremonies pleased the deities, they would send rains to green Swaziland’s fields and forests, rains that would dampen the king’s palace and his family’s new cars, rains that would fall upon the graves and the barren avocado trees, and rains that would soak the crumbling homes where people like May struggle against illness and neglect.

Postscript: After May was interviewed for this story, she was taken to a hospital, diagnosed with pneumonia, and given intravenous doses of antibiotics. May and her daughters then went to Hope House, a relief center operated by Roman Catholic nuns, where they received shelter and food to supplement May’s new regimen of ARVs.