but other times productive.
IV. Earlier on after a year, the patient may be so weak that even when taken to hospital (not much can be done due to late reporting), goes into chronicity and death.18
Like the local people, Lwegaba blamed Slim on the young fishermen and smugglers who had flocked to the lakeshore to exploit the Nile perch fisheries and the magendo economy. ‘Since perch-fishing began,’ an investigator noted,
temporary fishing camps of grass huts and sheds have grown up seasonally on the lakeshore, with predominantly male populations. Male labour relies, for food, drink and sexual services, on cafés, teashops, and bars, largely run by women. Each camp is associated with particular farming communities, which may be at a distance of up to 15 kilometres from the shore.19
It was probably in these fishing camps and neighbouring villages that partner exchange reached the frequency required to raise HIV to the epidemic levels elsewhere found only in the urban environments of Kinshasa or Kigali. Fifteen years later researchers studied such a fishing community in Masaka district. Its men had on average one new sexual partner every twelve days. Some 41 per cent of their partners were regular and 59 per cent casual; 85 per cent were contacts within the village, 8 per cent in other fishing villages, and 6 per cent in the nearby trading town. The village women, in turn, had 90 per cent of their sexual contacts with other villagers and 42 per cent with casual, paying clients. Such promiscuity was highly localised, so that HIV prevalence in different parishes of the district in the mid 1990s was to range from 4 per cent to 20 per cent. ‘It is our mating patterns that are finishing us off,’ a researcher was told.20
Although this epidemic began in the countryside, the difficulty of transmitting HIV makes it likely that it would have died away if it had not been carried to more open sexual networks in trading centres, the capital, and eventually the entire East African region. The researchers in Masaka found surprisingly little sexual exchange between village and town, but they did find that sexual activity varied enormously between individuals.21 It was perhaps hyperactive and mobile individuals who transmitted HIV to the main-road trading centres where it next flourished. In the Kagera region, for example, the virus appears to have been carried from border trading posts to inland commercial centres like Kamachumu, long a focus of coffee marketing and politics. Thence it spread to the regional capital, Bukoba. By 1987 prevalence among those aged 15–24 was 24.2 per cent in Bukoba town (reaching 42 per cent in its lowest-status section) and 10 per cent in the neighbouring Bukoba and Muleba rural districts.22 Once the virus was established in trading towns, workers carried it back to hitherto unaffected villages. In the Kagera village studied by Gabriel Rugalema, for example, Aids was introduced in 1987 by ‘a woman with an unstable marriage who worked part-time as a commercial sex worker in Rwamishenye (a suburb of Bukoba town). She came back to the village after she had been weakened by infections and died a few weeks later.’ Another 18 women and 41 men died there during the next nine years:
A majority of the men who died were involved in off-farm income generation, particularly those who had worked as itinerant traders. Others included carpenters, masons, and casual labourers . . . Only six of the deceased men could be strictly classified as full-time farmers. . . . As for the women, the majority of the deceased were, as may be expected, full-time farmers.23
In Rakai district, similarly, a computer simulation suggests that the annual incidence of new infections among people aged 15–24 peaked in 1987 at about 8.3 per cent.24 Two years later, prevalence among men and women aged over 13 varied from 26 and 47 per cent respectively in main-road trading centres to 22 and 29 per cent in local trading village and 8 and 9 per cent in agricultural villages. In 1990–2, 31 per cent of all households in Rakai district contained an infected member. The worst impact was in the truck-stop towns along the trans-African highway between Kampala and Kigali, notably Lyantonde, where HIV was found in 67 per cent of the bar girls tested in 1986 and in 53 per cent of the entire adult population in 1989.25
The prominence of the trans-African highway was one indication that the epidemic had by the mid 1980s spread far beyond the west lake region. Three categories of mobile men appear especially to have carried it. One was the military: General Amin’s soldiers retreating from the infected border region in 1978–9, Tanzanian troops pursuing them through western and northern Uganda, and Ugandan forces seeking to repress rebellion in the north and east during the 1980s. The northern Gulu district, the chief source of Amin’s troops, recorded 15 per cent prevalence among pregnant women in 1987 and probably became the main route by which HIV entered the southern Sudan and was carried northwards by soldiers and refugees to Khartoum, where in 1998–9 nearly half of those infected had the D subtype found in Uganda and DR Congo.26 The western Ugandan districts of Kabale, Kasese, and Kabarole, prominent in early Aids returns, may also have been infected initially by rival armies. Military actions during the 1980s in Luweero and Soroti districts, further east, were probably important in spreading the disease there.27
A second group carrying the virus were long-distance drivers who infected or were infected by bar girls at their overnight stops in towns like Lyantonde. One study of 68 drivers in Kampala in 1986 reported that 35 per cent already had HIV.28 The third occupational group, with a more diffuse and less certain impact, were migrant labourers carrying the disease to rural homes. ‘With the AIDS pandemic,’ a hospital in the remote south-west of Uganda reported in 1991, ‘it is still the returnees to Bufumbira that introduce this deadly disease into the population which otherwise knows no promiscuity. Among the returnees are also counted the taxi drivers and the long-distance truck drivers.’29
Kampala held a special position. In retrospect, its main prison may have held cases as early as 1979 or 1980, when patients with aggressive Kaposi’s sarcoma also appeared in the main Mulago Hospital, soon followed by others with the chronic diarrhoea and wasting of Slim disease.30 Nobody linked these infections to the emerging Aids epidemic elsewhere in the world until late in 1984, by which time HIV was already entrenched in the city and spreading rapidly. ‘It all started as a rumour,’ the chief epidemiologist later reflected. ‘Then we found we were dealing with a disease. Then we realised that it was an epidemic. And, now we have accepted it as a tragedy.’31 Studies of prevalence among pregnant women in Kampala showed 11 per cent in 1985, 14 per cent in 1986, 24 per cent in 1987 – then the highest figure in the world outside Kigali – and a peak of over 30 per cent in 1989.32 Notably, however, Kampala’s epidemic was not focused on a core group of sex workers and their clients, in contrast to other East African cities. There was little association between HIV infection and commercial sex, which was unorganised, diverse, illegal, and impossible to distinguish from other sexual relationships involving gifts.33 Instead, Kampala’s sexual pattern was closer to Kinshasa’s, with more young women than young men, sexual debut at an average age of fourteen in Uganda generally in 1989, 69 per cent of men and 74 per cent of women aged 15–19 having sexual experience, a rising age at marriage, and many young women whose dependence on gifts from male lovers had been accentuated by the economic disorder of the 1970s and 1980s.34 It was a pattern vulnerable to HIV but capable of change.
Although reports of a novel disease in Rakai reached the authorities in 1982–3, Uganda was then in the midst of civil war and no action was taken until Lwegaba’s report coincided late in 1984 with laboratory evidence that patients at Mulago Hospital with Kaposi’s sarcoma were infected with HIV. Milton Obote’s government, then in power, ordered an investigation. A team visited Masaka, conducted examinations at Mulago, and concluded that Slim was ‘part of the spectrum’ of Aids, although with opportunistic symptoms specific to East Africa. Ruling out transmission by casual or indirect means, the researchers blamed heterosexual promiscuity, perinatal transmission, and blood transfusion, estimating that Mulago Hospital might be creating two new cases each day. HIV-positive patients at Mulago reported on average twice as many sexual partners as HIV-negative patients. Another risk factor was a sexually transmitted infection, especially genital ulcer disease.35
Uganda’s
