In Malawi the only people doing good business are the coffin-makers

This feature is one of a ten-country series that first appeared in the Belgian newspapers Le Soir (French) and De Standaard (Dutch). Prepared in cooperation with MSF, the series explores the lives of the civilian populations trying to survive in conflicts the world has all but forgotten.

This article first appeared in De Standaard.

In the spring 3.2 million Malawians were in danger of dying from hunger if food aid didn't arrive. It didn't make the papers. The bulky reports from international bodies did. The causes of food shortages in this impoverished country - the vicious circle of drought and flood, the weak economy, lack of crop variety, badly run agriculture, and corruption - are the classic ones.

Except for one: AIDS.

Coffin-making is a booming business in poverty-stricken Malawi. Coffins come in three sizes, sandpapered or varnished. Margaret had chosen one for her sister a few years ago, when she succumbed to matantanda athu omwewa - "that new sickness of ours". In October of last year, Margaret's only surviving sister stood in the same workshop. Margaret, 29, reduced to skin and bone, with a faraway look in her eyes, had struggled hopelessly for months. Without her husband.

When she received her death sentence in May, he scarpered. She died in her little hut in Nansato, in the forest, before the eyes of her two children and her sister's orphans. In Malawi only children and grandparents survive.

Overshadowed by larger neighbours such as Zimbabwe, in Malawi too the AIDS pandemic is wiping out a whole generation. The generation that keeps the country ticking. Gaps are appearing in the hospitals and schools. By 2010 it is reckoned that half of all nurses, police, teachers, and soldiers will have succumbed to AIDS.

A quarter of the education budget is spent on teachers' burials. Hundreds of officials' jobs are vacant. Shortages loom of fishermen, transport workers, engineers, and technicians. One out of six members of parliament has been mown down. Those still at work are either weakened by illness or have to care for sick family members. When they're not rushing from one funeral to another.

Nearly one million of the 11.5 million Malawians are infected with the virus. In the southern provinces and in the towns it affects more than a quarter of the population; more than a quarter of the working population is infected. Officially, the country has almost half a million AIDS orphans.

Every day 140 people die of diseases such as tuberculosis, which their immune system cannot fight as it is undermined by the virus. Life expectancy has fallen to 36. "AIDS is killing Africa", shriek the preventive posters on the streets of the big towns. As a warning. But it's a fact.


The only titbit of news from Malawi that made it into the media in recent months was about rioting by angry Muslims after five suspected Al Qaeda members were arrested with CIA help. In the spring 3.2 million Malawians were in danger of dying from hunger if food aid didn't arrive. It didn't make the papers. The bulky reports from international bodies did. The causes of food shortages in this impoverished country - the vicious circle of drought and flood, the weak economy, lack of crop variety, badly run agriculture, and corruption - are the classic ones.

Except for one: AIDS. More than eight out of ten Malawians live from agriculture. Now that the virus is ravaging the country, more and more grandparents and children find themselves in charge of farms. They don't have the knowledge needed, or else they can't handle the work. Workers to help bring in the harvest are becoming scarcer. Seven out of ten families have already seen their incomes reduced by the pandemic. A quarter of poor households either don't harvest or let their land lie fallow when family members are seriously ill, according to UNAIDS, the United Nations agency for combatting AIDS.

This year's harvest was better than expected. But the food situation remains precarious. "What good are medicines for AIDS if the sick person has nothing to eat?", asked James Morris, director of the World Food Programme, in the course of a crisis appeal last spring. "Someone fighting against malaria, TB, cholera, and polio must have enough food. That's the most important medication in the fight against AIDS."

Give us money

It is also the only medicament within Malawians' reach. "The political will to stop the epidemic is there," says Roger Teck, head of the Médecins Sans Frontières mission in Malawi. "But the money isn't." Eighty percent of the health budget is financed by foreign donors. The cash-starved health services are already creaking under the consequences of the AIDS pestilence. Seventy per cent of hospital beds are occupied by AIDS patients. Doctors who are not themselves sick often flee abroad. Underpaid nurses give up in despair.

Some 3,000 sufferers now receive the expensive antiretroviral drugs that slow down AIDS: some pay, some get them free, such as the 875 people covered by the Médecins Sans Frontières project. If Malawians, with wage packets worth half a euro per day, want the pills, the cash will have to come from foreign pockets. For even if the pharmaceutical industry lets prices fall and even if the government only buys generic medicines, the antiretroviral drugs remain out of reach for the average Malawian.

The UN's Global Fund to Fight Aids is taking shape, but donors have kept their purse-strings tight. Instead of 1.62 billion euro for the 300,000 patients who urgently need the treatments, Malawi is getting 196 million dollars for 25,000 patients over five years. "So who's going to live, and who's going to die?", asked vice-president Justin Malewezi in The Guardian in the spring.

"A country where the health services are on their last legs cannot even cope with those 25,000," believe the donors. They worry that - due to non-compliance - a resistant virus might emerge in Malawi and then find its way to the West. "We have to find a compromise between the sophisticated approach in the West and the enormous needs here in Malawi. We will just have to dare to be ambitious," says Teck.

Malawi does have a successful TB programme, which treats 70 per cent of sufferers - a higher than average figure. Those pills too must be taken conscientiously and punctually, and patients do so at home, under the watchful eye of local health workers. Why can't the same be done for HIV? In many districts volunteers are already active in caring for AIDS sufferers, helping them and informing them. They should be able to keep them compliant. "Give us the money; we'll do it."


For as long as there remains no hope, many people prefer to just stick their heads in the sand. The thousands who are buried every month always die after "a short illness". So the country was stunned when in February a minister, Thengo Mayola, gave his emotional account of the death of two sons and a daughter from AIDS. "They should have looked after me and buried me. Now I have buried them while they were still young. Let us now, finally, say openly that AIDS kills."

"The stigma is still great," says Teck from MSF. The taboo about sex too. Malawi is very conservative - the strong influence of the Catholic and Protestant churches has a lot to do with that. But men go from Sunday Mass to prostitutes' bars and have unprotected sex. Promiscuity is a sign of virility. Age-old cultural traditions such as the sexual initiation of young girls by one man in the village also favour the deadly progress of the disease.

Churches teach people to read and to write and how to dig wells, but they refuse to promote condoms. The government trumpets their merits all over the place, on massive advertising hoardings in the towns and on murals in the brothels. "In the towns just about everyone knows that a condom is safer," says Teck. But according to a recent survey 60 to 70 per cent of young people surveyed didn't use one the last time they had sex. Habits are hard to break.

The hand that rocks the cradle...

"This generation of adults is lost," says Teck. "So the government is trying to save the new one." The rate of infection among children under fourteen is only a fraction of that among adults. The Government is making use of free school meals from UNICEF in its efforts to keep children in school, where they learn to protect themselves against AIDS. But poverty is driving girls to prostitution and boys to any kind of job that can help raise the family income. Parents take their children out of school because they cannot afford the books and uniforms.

The fate of the hundreds of thousands of AIDS orphans is a particular cause of concern: too small to look after themselves, and a burden on family members who can barely keep their own heads above water. The extended family - most Africans' social security system - is unravelling.

Last month the University of Heidelberg and the World Bank sounded a pessimistic note about the new generation in southern Africa. According to The Long-Run Economic Costs of Aids, the loss of human capital - the knowledge and expertise, the experience that parents cannot pass on to their children - is gradually destroying societies. They predict that children will leave school on a massive scale in order to get an income; the economy will depend on child labour, with the result that wages, and thus purchasing power, will fall and the economy will slide backwards in time.

Many observers found this vision too pessimistic, as its authors seem to assume that nothing will be done to put a stop to the creeping murder of a generation. "We can now see a slight downward trend in recent figures for AIDS infection in Malawi," says Teck. "Prevention is having an effect. It is too soon to cry victory. But it looks as if there's light at the end of this tunnel."