It's interesting being back in South Africa on a reporting trip after a long gap of fourteen years. It allows a reporter to compare the still-vivid impressions of a place that made revolutionary social and political change in the mid-90s with the young democracy of today.
The optimistic and confident place that held its first all-race elections in 1994 has scored many successes, but a devastating setback throws all the good news into shadow: South Africa is among a handful of countries with the highest rates of HIV infection in the world.
It is hard to overstate what that means to a developing country. Instead of investing its still-modest resources in making its people smarter, richer, and healthier, South Africa must spend billions to keep very sick people alive, care for burgeoning ranks of young orphans, and cope with the loss of hundreds of thousands of its people during their most productive years.
A NewsHour team is in South Africa to report on South Africa's struggle with HIV/AIDS, and the twin threat of tuberculosis, now the number one killer of HIV-positive adults. Thursday, we were in the Western Cape Province, home to some of the world's highest rates of tuberculosis infection, some 80 percent in the valleys north and west of Cape Town.
One doctor told me of communities with rates so high that suffering the disease is seen as inevitable. If you ask poor people in the Western Cape if they've had TB they don't answer "yes" or "no," but "not yet."
Keep in mind that tuberculosis is a curable disease, well known, and easily detected. When you ask doctors why this part of South Africa suffers so heavily from a disease almost unknown in many places, they list high rates of poverty, cramped living conditions, alcoholism and HIV among the reasons.
It stands to reason. HIV suppresses the immune system, the human body's battery of responses to germs and viruses. An immune-suppressed body is not only unable to fight off TB, but may move more quickly from an "encapsulated" infection, dormant in the lung, to a full-blown, dangerously contagious form of the disease.
These days, in clinics across the country, South Africans are found to be HIV-positive when they come to the doctor fearing they have contracted tuberculosis. At that point, physicians have to make a choice: if untreated, both diseases are fatal. The TB drugs and the increasingly available antiretrovirals used to treat HIV don't interact well, so a doctor must ascertain which of the two is the bigger threat at the moment.
The most desirable course in this very undesirable situation is to attack the faster moving tuberculosis first, then move on to the HI V/AIDS treatment. However, when a patient arrives for a first consultation with a dangerously suppressed immune system and high "loads" of HIV, there may be no time to isolate the two treatments, as AIDS may kill the infected person before the TB drugs have had a chance to work.
Earlier this week in a Johannesburg clinic I met 53-year-old Patrick Shongwe, a slight, friendly man who's been on antiretrovirals for three and a half years. He told me he feels great, and that he's certain the AIDS drugs saved his life. When he first came to the crowded clinic his face, his tongue and the inside of his mouth were covered in sores. He was losing strength in his legs and finding it increasingly difficult to stand.
Shongwe and I are about the same age. I began our conversation giving him the kind of deference I am accustomed to giving an older man. I was stunned when he gave me his age, and was reminded of the toll lifelong poverty can take on people, regardless of disease.
Shongwe said he was sure he would be in even better shape today if he was able to find work. The South African social safety net doesn't provide much for a man like him, and he said until he finds work he expects to be hungry much of the time. "I want to work. I am well enough to work," Shongwe says, "but things are bad in Joburg right now, there is no work anywhere."
The worldwide economic crisis is cutting demand for the raw materials South Africa exports, drying up exports of manufactured goods to the rest of Africa, and hobbling the tourist trade from the developed world, in other years flocking to game parks and beaches drenched in sun when Europe and North America are shivering through winter.
Shongwe looks up at the downturn from the bottom of the economy. Health Minister Barbara Hogan sits at the top of the organizational chart of South Africa's war on AIDS, and worries not only about the sufferings of her people, but wonders how the downturn may change the willingness to help in the richest countries of the world.
Hogan arrived at the health ministry after a lifetime of public service, political activism, and resistance to apartheid. In the 1980s, she became the first woman sentenced to life in prison for treason in South Africa. She served nine years of that life sentence before the thaw between black political movements and the dominant white minority, with whom Hogan shared a skin color but not a world view.
For much of the presidency of South Africa's second post-apartheid president, Thabo Mbeki, the country's health policies suffered from a mind-boggling mix of denial, folklore and wishful thinking.
The Mbeki government won high praise for steering the country to economic stability and high rates of growth. But the president's speculation that HIV doesn't cause AIDS, and his appointment of a health minister who suggested traditional herbal remedies for AIDS over antiretrovirals, brought discredit to the president, as hundreds of thousands of his countrymen died and his national health service delayed rolling out life-saving treatment.
Hogan freely concedes that the terrible reputation of her predecessors bought her some time for a honeymoon, but the crisis is so pressing it can't last long.
In the next few months, South Africa's voters will head to the polls again, and right now the favorite for election is Jacob Zuma, an African National Congress stalwart who hails from the epicenter of his country's HIV quake.
He's attracted critical attention for admitting to having sex with an HIV positive woman without using protection. Accused of rape, he said in his own defense that the sex was consensual, and that he minimized his risk of AIDS by showering immediately after. Not exactly the message a future leader should be sending a country devastated by the disease, says AIDS activist Rebecca Hodes. Now she and her NGO comrades across South Africa are wondering, if Zuma wins, will he keep Minister Hogan?
Editor's note: Watch for Ray Suarez's reports from South Africa on the NewsHour next month.